    Electronic Health Records: DOD and VA Have Increased Their
    Sharing of Health Information, but More Work Remains (28-JUL-08,
    GAO-08-954).

    Under the National Defense Authorization Act for Fiscal Year
    2008, the Department of Defense (DOD) and the Department of
    Veterans Affairs (VA) are required to accelerate the exchange of
    health information between the departments and to develop systems
    or capabilities that allow for full interoperability (generally,
    the ability of systems to use data that are exchanged) and that
    are compliant with federal standards. The act also established a
    joint interagency program office to act as a single point of
    accountability for the effort, whose function is to implement
    such systems or capabilities by September 30, 2009. Further, the
    act required that GAO semi-annually report on the progress made
    in achieving these goals. For this first report, GAO describes
    the departments' progress to date in sharing electronic health
    information, developing electronic health records that comply
    with federal standards, and setting up the joint interagency
    program office. To do so, GAO reviewed its past work, analyzed
    agency documentation, and conducted interviews with agency
    officials.
    -------------------------Indexing Terms-------------------------
    REPORTNUM:   GAO-08-954
        ACCNO:   A83103
      TITLE:     Electronic Health Records: DOD and VA Have Increased
    Their Sharing of Health Information, but More Work Remains
         DATE:   07/28/2008
      SUBJECT:   Data collection
    	     Data integrity
    	     Data storage
    	     Data transmission
    	     Electronic data interchange
    	     Electronic health records
    	     Government information dissemination
    	     Health care programs
    	     Information disclosure
    	     Information technology
    	     Interagency relations
    	     Interoperability
    	     Medical information systems
    	     Medical records
    	     Program evaluation
    	     Records
    	     Records management
    	     Reporting requirements
    	     Standards
    	     Standards evaluation
    	     Strategic planning
    	     Information sharing
    	     Program goals or objectives
    	     Program implementation

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    GAO-08-954

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    Report to Congressional Requesters:

    United States Government Accountability Office:
    GAO:

    July 2008:

    Electronic Health Records:

    DOD and VA Have Increased Their Sharing of Health Information, but More
    Work Remains:

    GAO-08-954:

    GAO Highlights:

    Highlights of GAO-08-954, a report to congressional requesters.

    Why GAO Did This Study:

    Under the National Defense Authorization Act for Fiscal Year 2008, the
    Department of Defense (DOD) and the Department of Veterans Affairs (VA)
    are required to accelerate the exchange of health information between
    the departments and to develop systems or capabilities that allow for
    full interoperability (generally, the ability of systems to use data
    that are exchanged) and that are compliant with federal standards. The
    act also established a joint interagency program office to act as a
    single point of accountability for the effort, whose function is to
    implement such systems or capabilities by September 30, 2009.

    Further, the act required that GAO semi-annually report on the progress
    made in achieving these goals. For this first report, GAO describes the
    departments� progress to date in sharing electronic health information,
    developing electronic health records that comply with federal
    standards, and setting up the joint interagency program office. To do
    so, GAO reviewed its past work, analyzed agency documentation, and
    conducted interviews with agency officials.

    What GAO Found:

    DOD and VA are sharing some, but not all, electronic health information
    at different levels of interoperability. Specifically, pharmacy and
    drug allergy data on about 18,300 patients who receive care from both
    departments are exchanged at the highest level of interoperability�that
    is, in computable form; at this level, the data are in a standardized
    format that a computer application can act on (for example, to provide
    alerts to clinicians of drug allergies). In other cases, data can be
    viewed only�a lower level of interoperability that still provides
    clinicians with important information. However, not all electronic
    health information is yet shared, and information is still captured on
    paper at many DOD medical facilities. According to the departments, a
    DOD/VA Information Interoperability Plan (targeted for approval in
    August 2008) is to address these and other issues and define tasks
    required to guide the development and implementation of an
    interoperable electronic health record capability. If properly
    developed and implemented, the plan could help the departments achieve
    the goal of seamless sharing of health information.

    DOD and VA have agreed upon numerous common standards that allow them
    to share health data, which include standards that are part of current
    and emerging federal interoperability specifications. This
    collaboration provided the essential foundation for the departments to
    begin sharing computable health data. The departments are currently
    participating in recent initiatives led by the Office of the National
    Coordinator for Health Information Technology (within the Department of
    Health and Human Services) that are aimed at promoting the adoption of
    federal standards and broader use of electronic health records. These
    initiatives include identifying relevant existing standards,
    identifying and addressing overlaps and gaps in the standards, and
    developing interoperability specifications and certification criteria
    based on these standards. The involvement of the departments in these
    activities is an important mechanism for aligning their electronic
    health records with emerging federal standards.

    In establishing the joint interagency program office, Congress directed
    the departments to develop an implementation plan for setting up the
    office and carrying out related activities (such as validating and
    establishing requirements for interoperable health capabilities). The
    departments� effort to set up the program office is still in its early
    stages. Leadership positions in the office are not yet permanently
    filled, staffing is not complete, and facilities to house the office
    have not been designated. Further, the implementation plan is currently
    in draft, and although it includes schedules and milestones, dates for
    several activities have not yet been determined (such as implementing a
    capability to share immunization records), even though all capabilities
    are to be achieved by September 2009. Without a fully established
    program office and a finalized implementation plan with set milestones,
    the departments may be challenged in meeting the required date for
    achieving interoperable electronic health records and capabilities.

    What GAO Recommends:

    GAO is recommending that the departments give priority to fully
    establishing the program office and finalizing the implementation plan.
    Commenting on a draft of this report, DOD and VA concurred with GAO�s
    recommendations and described actions planned or being taken to address
    them.

    To view the full product, including the scope and methodology, click on
    [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-954]. For more
    information, contact Valerie Melvin at (202) 512-6304 or
    melvinv@gao.gov.

    [End of section]

    Contents:

    Letter:

    Results in Brief:

    Background:

    DOD and VA Are Currently Sharing Health Information at Different Levels
    of Interoperability, but More Work Remains to Share All Health
    Information:

    DOD and VA Have Adopted Standards to Allow Sharing and Are Taking Steps
    to Follow Federal Standards, Which Continue to Evolve:

    DOD and VA Have Taken Steps to Establish the Joint Interagency Program
    Office, but the Office Does Not Yet Have Permanent Leadership, Staff,
    or Facilities:

    Conclusions:

    Recommendations for Executive Action:

    Agency Comments and Our Evaluation:

    Appendix I: Scope and Methodology:

    Appendix II: Comments from the Department of Defense:

    Appendix III: Comments from the Department of Veterans Affairs:

    Appendix IV: GAO Contact and Staff Acknowledgments:

    Related GAO Products:

    Tables:

    Table 1: Current and Emerging Interoperability Specifications:

    Table 2: Selected DOD Legacy Medical Information Systems and Databases:

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

    Figure:

    Figure 1: Levels of Interoperability:

    Abbreviations:

    AHLTA: Armed Forces Health Longitudinal Technology Application:

    BHIE: Bidirectional Health Information Exchange:

    CHCS: Composite Health Care System:

    CHDR: Interface between DOD's Clinical Data Repository (CDR) and VA's
    Health Data Repository (HDR):

    CIS: Clinical Information System:

    DOD: Department of Defense:

    FHIE: Federal Health Information Exchange:

    HHS: Department of Health and Human Services:

    HITSP: Healthcare Information Technology Standards Panel:

    IT: information technology:

    LDSI: Laboratory Data Sharing Interface:

    OMB: Office of Management and Budget:

    SNOMED CT: Systematized Nomenclature of Medicine Clinical Terms:

    VA: Department of Veterans Affairs:

    VistA: Veterans Health Information Systems and Technology Architecture:

    [End of section]

    United States Government Accountability Office:
    Washington, DC 20548:

    July 28, 2008:

    Congressional Committees:

    For the last decade, the Department of Defense (DOD) and the Department
    of Veterans Affairs (VA) have been pursuing initiatives to share data
    between their health information systems. The departments' efforts have
    included working toward a long-term vision of a single "comprehensive,
    lifelong medical record"[Footnote 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 share
    health information, including responding to current military crises.

    However, the two departments cannot yet share all essential health
    information,[Footnote 2] prompting continuing calls for progress in
    this area. In May 2003, a presidential task force recommended that DOD
    and VA develop and deploy bidirectional electronic health records by
    fiscal year 2005. In July 2007, the President's Commission on Care for
    America's Returning Wounded Warriors reported that the departments had
    continued to develop independent, stand-alone systems and recommended
    that the two departments move rapidly to make all essential health
    information available to clinicians.[Footnote 3]

    To expedite the departments' efforts to exchange health care
    information, Congress included in the National Defense Authorization
    Act for Fiscal Year 2008 provisions that DOD and VA jointly develop and
    implement electronic health record systems or capabilities and
    accelerate the exchange of health care information.[Footnote 4] The act
    also required that these systems or capabilities be compliant with
    applicable interoperability[Footnote 5] standards, implementation
    specifications, and certification criteria of the federal government.
    The act established a joint interagency program office to act as a
    single point of accountability for the effort, with the function of
    implementing, by September 30, 2009, electronic health record systems
    or capabilities that allow for full interoperability of personal health
    care information between the departments.

    In addition, the act required that GAO semi-annually report on the
    progress that DOD and VA have made in achieving the goal of fully
    interoperable personal health care information. As agreed with the
    committees of jurisdiction, our objectives for this first report are to
    describe (1) the departments' progress to date on developing electronic
    health records systems or capabilities that allow for full
    interoperability of personal health care information between the
    departments; (2) steps taken by the departments to ensure that their
    health records comply with applicable interoperability standards,
    implementation specifications, and certification criteria of the
    federal government; and (3) efforts to set up the joint interagency
    program office.

    To carry out these objectives, we reviewed our past work in this area;
    [Footnote 6] analyzed agency documentation (including schedules and
    benchmarks for the establishment of the joint interagency program
    office, program documents, and health information standards); and
    conducted interviews with officials from DOD, VA, and the Department of
    Health and Human Services' Office of the National Coordinator for
    Health Information Technology. We also visited two medical sites
    (Walter Reed Army Medical Center and the Washington, D.C., VA Medical
    Center) to observe the sharing capabilities of the electronic health
    information systems that are currently in place.

    We conducted this performance audit from March 2008 through July 2008
    in accordance with generally accepted government auditing standards.
    Those standards require that we plan and perform the audit to obtain
    sufficient, appropriate evidence to provide a reasonable basis for our
    findings and conclusions based on our audit objectives. We believe that
    the evidence obtained provides a reasonable basis for our findings and
    conclusions based on our audit objectives. For more details on our
    scope and methodology, see appendix I.

    Results in Brief:

    DOD and VA have established and implemented mechanisms to achieve
    interoperable sharing of some, but not all, electronic health
    information. This information is shared at different levels of
    interoperability. Specifically, pharmacy and drug allergy data on about
    18,300 shared patients (that is, patients who receive care from both
    departments) are exchanged at the highest level of interoperability--
    that is, in computable form. At this level, the data are in a
    standardized format that a computer application can act on (for
    example, to provide alerts to clinicians of drug allergies). In other
    cases, data that are shared cannot be acted upon by an application but
    can be viewed--a lower level of interoperability that nonetheless
    provides clinicians with important health information. Viewable data
    that are currently shared include, among other things, microbiology
    results, cytology reports, and chemistry and hematology reports.
    However, not all electronic health information is yet shared; for
    example, immunization records and history, data on exposure to health
    hazards, and psychological health treatment and care records. Finally,
    although VA's health information is all captured electronically, not
    all health data collected by DOD are electronic--many DOD medical
    facilities use paper-based health records. According to the
    departments, a DOD/VA Information Interoperability Plan (targeted for
    approval in August 2008) is to address issues including future sharing
    and paper records and define tasks required to guide the development
    and implementation of an interoperable electronic health record
    capability. If this plan includes the essential elements needed to
    guide the departments in achieving their long-term goal of seamless
    sharing of health information, it could improve the prospects for the
    achievement of this goal.

    DOD and VA have agreed upon numerous common standards that allow them
    to share health data, which include standards that are part of current
    and emerging federal interoperability specifications. The foundation
    built by this collaborative process has allowed DOD and VA to begin
    sharing computable health data (the highest level of interoperability).
    Continuing their historical involvement in efforts to agree upon
    standards for the electronic exchange of clinical health information,
    the departments are also participating in recent ongoing initiatives
    led by the Office of the National Coordinator for Health Information
    Technology (within the Department of Health and Human Services) that
    are aimed at promoting the adoption of federal standards and broader
    use of electronic health records.[Footnote 7] As federal standards
    evolve and are put into place, the involvement of the departments in
    these initiatives is an important mechanism for ensuring that their
    electronic health records are aligned with emerging standards.

    To accelerate DOD's and VA's ongoing interoperability efforts, Congress
    directed that a joint interagency program office be developed and
    required the departments to develop an implementation plan for setting
    up the office and carrying out related activities (such as validating
    and establishing requirements for interoperable health capabilities).
    However, the departments' effort to set up the program office is still
    in its early stages. Leadership positions in the office are not yet
    permanently filled, staffing is not complete, and facilities to house
    the office have not been designated. Further, the implementation plan
    is currently in draft, and although it includes schedules and
    milestones, dates for several activities have not yet been determined
    (such as implementing a capability to share immunization records), even
    though all capabilities are to be achieved by September 2009. Without a
    fully established program office and a finalized implementation plan
    with set milestones, the departments may be challenged in meeting the
    required date for achieving interoperable electronic health records and
    capabilities.

    To better ensure the successful attainment of interoperable electronic
    health record systems or capabilities, we are recommending that the
    Secretaries of Defense and Veterans Affairs give priority to fully
    establishing the joint interagency program office and finalizing the
    draft implementation plan.

    In providing written comments on a draft of this report, the Assistant
    Secretary of Defense for Health Affairs and the Secretary of Veterans
    Affairs concurred with the report's recommendations. (The departments'
    comments are reproduced in app. II and app. III, respectively.) The
    Assistant Secretary of Defense for Health Affairs stated that high
    priority will be given to fully establishing the Joint Interagency
    Program Office, with specific focus on expanding efforts related to
    permanent leadership, staff, and facilities. VA's comments describe
    actions that begin to address our recommendations. Among the actions,
    the department noted that it plans to appoint the Deputy Director for
    the Joint Interagency Program Office by October 2008, and to hire
    permanent program staff by December 2008. In addition, VA stated that
    by October 31, 2008, the departments expect to identify the milestones
    and timelines for defining requirements to support interoperable health
    records. If the actions planned are properly implemented, they should
    help ensure that DOD and VA will be successful in meeting their goals
    for sharing interoperable health information.

    Background:

    As we have reported,[Footnote 8] the use of information technology (IT)
    to electronically collect, store, retrieve, and transfer clinical,
    administrative, and financial health information has great potential to
    help improve the quality and efficiency of health care and is critical
    to improving the performance of the U.S. health care system. Critical
    health information for a patient seeking treatment (such as allergies,
    current treatments or medications, and prior diagnoses) has,
    historically, been scattered across paper records kept by many
    different caregivers in many different locations, making it difficult
    for a clinician to access all of a patient's health information at the
    time of care. Lacking access to these critical data makes it
    challenging for a clinician to make the most informed decisions on
    treatment options, potentially putting the patient's health at greater
    risk. The use of electronic health records can help provide this access
    and improve clinical decisions.[Footnote 9]

    Electronic health records are particularly crucial for optimizing the
    health care provided to military personnel and veterans. While in
    military status and later as veterans, many DOD and VA patients tend to
    be highly mobile and may have health records residing at multiple
    medical facilities within and outside the United States. Making such
    records electronic can help ensure that complete health care
    information is available for most military service members and veterans
    at the time and place of care, no matter where it originates.

    Key to making health care information electronically available is the
    ability to share that data among health care providers--that is,
    interoperability. Interoperability is the ability for different
    information systems or components to exchange information and to use
    the information that has been exchanged. This capability is important
    because it allows patients' electronic health information to move with
    them from provider to provider, regardless of where the information
    originated. If electronic health records conform to interoperability
    standards, they can be created, managed, and consulted by authorized
    clinicians and staff across more than one health care organization,
    thus providing patients and their caregivers the necessary information
    required for optimal care. (Paper-based health records--if available--
    also provide necessary information, but unlike electronic health
    records, paper records do not provide decision support capabilities,
    such as automatic alerts about a particular patient's health, or other
    advantages of automation.)

    Interoperability can be achieved at different levels. At the highest
    level, data are in a format that a computer can understand and operate
    on, whereas at the minimum type of interoperability, the data are in a
    format that is viewable, so that information is available for a human
    being to read and interpret. Figure 1 shows various levels of
    interoperability and examples of the types of data that can be shared
    at each level.

    Figure 1: Levels of Interoperability:

    [See PDF for image]

    This figure is an illustration of the Levels of Interoperability. Each
    item requires increasingly more sophisticated IT and standardization:

    * Nonelectronic data: paper health records;
    * Unstructured, viewable electronic data: scanned information in PDF
    file;
    * Structured, viewable electronic data: uncoded textual information;
    * Computable electronic data: standardized, coded information.

    Source: GAO analysis based on data from the Center for Information
    Technology leadership.

    [End of figure]

    As the figure shows, paper records can be considered interoperable in
    that they allow data to be read and interpreted by a human being. In
    the remainder of this report, however, we do not discuss
    interoperability in this sense; instead, we focus on electronic
    interoperability, for which the first level of interoperability is
    unstructured, viewable electronic data. With unstructured data, a
    clinician would have to find needed or relevant information by scanning
    uncategorized information. The value of viewable data is increased if
    the data are structured so that information is categorized and easier
    to find. At the highest level, as shown, the computer can interpret and
    act on the data.

    Not all data require the same level of interoperability. For example,
    in their initial efforts to implement computable data, VA and DOD
    focused on outpatient pharmacy and drug allergy data because clinicians
    gave priority to the need for automated alerts to help medical
    personnel avoid administering inappropriate drugs to patients. On the
    other hand, for such narrative data as clinical notes, viewability may
    be sufficient. Achieving even a minimal level of interoperability is
    valuable for potentially making all relevant information available to
    clinicians.

    Efforts to Adopt and Implement Federal Interoperability Standards Are
    Ongoing:

    Any type of interoperability depends on the use of agreed-upon
    standards to ensure that information can be shared and used. In health
    IT, standards govern areas ranging from technical issues, such as file
    types and interchange systems, to content issues, such as medical
    terminology. Developing, coordinating, and agreeing on standards are
    only part of the processes involved in achieving interoperability for
    electronic health records systems or capabilities. In addition,
    specifications are needed for implementing the standards, as well as
    criteria and a process for verifying compliance with the standards.

    In December 2001, an effort to establish federal health information
    standards was initiated as an Office of Management and Budget (OMB) e-
    government project to enable federal agencies to build interoperable
    health data systems. This project, the Consolidated Health Informatics
    initiative, was a collaborative agreement among federal agencies,
    including DOD and VA, to adopt a common set of health information
    standards for the electronic exchange of clinical health information.
    Under the Consolidated Health Informatics initiative, DOD, VA, and
    other participating agencies agreed to endorse 20 sets of standards to
    make it easier for information to be shared across agencies and to
    serve as a model for the private sector. For example, standard
    medication terminologies were agreed upon, which DOD and VA then began
    to adopt in developing their data repositories.

    Recognizing the need for public and private sector collaboration to
    achieve a national interoperable health IT infrastructure, the
    President issued an executive order in April 2004 that called for
    widespread adoption of interoperable electronic health records by 2014.
    [Footnote 10] This order established the Office of the National
    Coordinator for Health Information Technology within the Department of
    Health and Human Services (HHS) with responsibility, among other
    things, for developing, maintaining, and directing the implementation
    of a strategic plan to guide the nationwide implementation of
    interoperable health IT in both the public and private health care
    sectors. Among its responsibilities as the chief advisor to the
    Secretary of HHS in this area, the Office of the National Coordinator
    is to report progress on the implementation of this strategic plan.

    Under the direction of HHS (through the Office of the National
    Coordinator), three primary organizations were designated to play major
    roles in expanding the implementation of health IT:

    * the American Health Information Community;

    * the Healthcare Information Technology Standards Panel, and:

    * the Certification Commission for Healthcare Information Technology.

    All three are involved in various processes related to electronic
    health records interoperability standards. The functions of these
    organizations are described in the following.

    American Health Information Community:

    The community is a federal advisory body created by the Secretary of
    HHS to make recommendations on how to accelerate the development and
    adoption of health IT, including advancing interoperability,
    identifying health IT standards, advancing nationwide health
    information exchange, and protecting personal health information.
    Formed in September 2005, the community is made up of representatives
    from both the public and private sectors.

    The American Health Information Community determines specific health
    care areas of high priority and develops "use cases"[Footnote 11] for
    these areas, which provide the context in which standards would be
    applicable. For example, the community has developed a use case
    regarding the creation of standardized, secure records of past and
    current laboratory test results for access by health professionals. The
    use case conveys how health care professionals would use such records
    and what standards would apply.

    Healthcare Information Technology Standards Panel (HITSP):

    Developed in October 2005, the Healthcare Information Technology
    Standards Panel (HITSP) is a public-private partnership, sponsored by
    the American National Standards Institute[Footnote 12] and funded by
    the Office of the National Coordinator. (HITSP is the successor to the
    Consolidated Health Informatics initiative, which was dissolved and
    absorbed into the panel on September 30, 2006.) The panel was
    established to identify competing standards for the use cases developed
    by the American Health Information Community and "harmonize" the
    standards. (Harmonization is the process of identifying overlaps and
    gaps in relevant standards and developing recommendations to address
    these overlaps and gaps.)

    For example, for the three initial use cases developed by the American
    Health Information Community, HITSP identified competing standards by
    converting the use cases into detailed requirements documents; it then
    examined and assessed more than 700 existing standards that would meet
    those requirements. From those 700 standards, the panel identified 30
    named standards and produced detailed implementation guidance
    describing the specific transactions and use of these named standards.
    This guidance is codified in an interoperability specification for each
    use case that integrates the standards.

    Each of the interoperability specifications developed by HITSP includes
    references to the identified standards or parts of standards and
    explains how they should be applied to specific topics. For example,
    among the standards referred to in one interoperability specification
    [Footnote 13] is the Systematized Nomenclature of Medicine Clinical
    Terms (SNOMED CT).[Footnote 14] This standard is to be used in the "Lab
    Result Terminology Component" of the specification.

    Once developed, the specifications are presented to the American Health
    Information Community, which assesses them for recommendation to the
    Secretary of HHS. The Secretary publicly "accepts" recommended
    specifications for a 1-year period of implementation testing, after
    which the Secretary can formally "recognize" the specifications and
    associated guidance as interoperability standards. This two-step
    process is intended to ensure that software developers have adequate
    time to implement recognized standards in their software. The year
    between acceptance and recognition allows the panel to refine its
    implementation guidance based on feedback from actual software
    implementation.

    Table 1 shows the current status of the interoperability specifications
    developed by HITSP.

    Table 1: Current and Emerging Interoperability Specifications:

    Interoperability specification: IS 01. Electronic Health Record (EHR)
    Laboratory Results Reporting;
    Description: To define specific standards to support the
    interoperability between electronic health records and laboratory
    systems and secure access to laboratory results and interpretations in
    a patient-centric manner;
    Status[A]: Version 2.1 recognized; Version 3.0 released (panel
    approved).

    Interoperability specification: IS 02. Biosurveillance;
    Description: To define specific standards that promote the exchange
    among healthcare providers and public health authorities of
    biosurveillance information (that is, information on areas such as
    human health, hospital preparedness, state and local preparedness,
    vaccine research and procurement, animal health, food and agriculture
    safety, and environmental monitoring);
    Status[A]: Version 2.1 recognized; Version 3.0 released (panel
    approved).

    Interoperability specification: IS 03. Consumer Empowerment;
    Description: To define specific standards needed to enable the exchange
    of data between patients and their caregivers;
    Status[A]: Version 2.1 recognized; Version 3.0 accepted (retitled
    Consumer Empowerment and Access to Clinical Information via Networks).

    Interoperability specification: IS 04. Emergency Responder Electronic
    Health Record (ER-EHR);
    Description: To define specific standards required to track and provide
    on-site emergency care professionals, medical examiner/fatality
    managers and public health practitioners with needed information
    regarding care, treatment, or investigation of emergency incident
    victims;
    Status[A]: Version 1.1 accepted.

    Interoperability specification: IS 05. Consumer Empowerment and Access
    to Clinical Information via Media;
    Description: To define specific standards needed to assist patients in
    making decisions regarding care and healthy lifestyles (that is,
    registration information, medication history, lab results, current and
    previous health conditions, allergies, summaries of healthcare
    encounters and diagnoses);
    Status[A]: Version 1.0 accepted.

    Interoperability specification: IS 06. Quality;
    Description: To define specific standards needed to benefit providers
    by providing a collection of data for inpatient and ambulatory care and
    to benefit clinicians by providing real-time or near-real-time feedback
    regarding quality indicators for specific patients;
    Status[A]: Version 1.0 accepted.

    Interoperability specification: IS 07. Medication Management;
    Description: To define specific standards to facilitate access to
    necessary medication and allergy information for consumers, clinicians,
    pharmacists, health insurance agencies, inpatient and ambulatory care,
    etc;
    Status[A]: Version 1.0 released (panel approved).

    Source: GAO analysis of HITSP data.

    [A] "Recognized" means that the specifications and associated guidance
    have been recognized by the Secretary of HHS as interoperability
    standards.

    "Accepted" means that the specifications and associated guidance have
    been accepted by the Secretary for a 1-year period of implementation
    testing.

    "Released (panel approved)" means that HITSP has completed and approved
    the specifications and associated guidance.

    [End of table]

    Each of the interoperability specifications in the table is associated
    with one of the seven use cases developed by the American Health
    Information Community in 2006 and 2007. The community is also
    developing six use cases for 2008, for which interoperability
    specifications have not yet been released:

    * Remote Monitoring;

    * Patient-Provider Secure Messaging;

    * Personalized Healthcare;

    * Consultation and Transfers of Care;

    * Public Health Case Reporting, and:

    * Immunizations & Response Management.

    Certification Commission for Healthcare Information Technology:

    The commission is an independent, nonprofit organization that certifies
    health IT products. HHS entered into a contract with the commission in
    October 2005 to develop and evaluate the certification criteria and
    inspection process for electronic health records. According to HHS,
    certification is to be the process by which the IT systems of federal
    health contractors are established to meet federal interoperability
    standards. Certification helps assure purchasers and other users of
    health IT systems that the systems will provide needed capabilities
    (including ensuring security and confidentiality) and will work with
    other systems without reprogramming. Certification also encourages
    adoption of health IT by assuring providers that their systems can
    participate in nationwide health information exchange in the future. In
    2006, the commission certified the first 37 ambulatory--or clinician
    office-based--electronic health record products as meeting baseline
    criteria for functionality, security, and interoperability. In 2007,
    the commission expanded certification to inpatient--or hospital--
    electronic health record products, which could significantly increase
    patients' and providers' access to the health information generated
    during a hospitalization. To date, the commission has certified over
    100 electronic health record products.

    Our Previous Work Has Emphasized the Importance of a National Strategy:

    Since 2005, we have reported and testified on the various actions that
    HHS and the Office of the National Coordinator have taken to advance
    nationwide implementation of health IT, which include the establishment
    of the American Health Information Community and related activities,
    selection of initial standards to address specific health areas, and
    the release in July 2004 of a framework for strategic action.[Footnote
    15]

    We pointed out in 2005 that this framework did not constitute a
    comprehensive national strategy with detailed plans, milestones, and
    performance measures needed to ensure that the outcomes of the
    department's various initiatives are integrated and its goals are met
    [Footnote 16]. As a result, we recommend that HHS establish detailed
    plans and milestones for each phase of the framework for strategic
    action and take steps to ensure that those plans are followed and
    milestones met.

    In this regard, in June 2008, the Office of the National Coordinator
    released a four-year strategic plan. Although we have not yet fully
    assessed this plan, if its milestones and measures for achieving an
    interoperable national infrastructure for health IT are appropriate,
    the plan could provide a useful roadmap to support the goal of
    widespread adoption of interoperable electronic health records.

    DOD and VA Have Been Pursuing Efforts to Exchange Health Information
    for a Decade:

    DOD and VA have been working to exchange patient health data
    electronically since 1998. 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 reviews in 2001 and 2002, we noted management
    weaknesses, such as inadequate accountability and poor planning and
    oversight, and recommended that the departments apply principles of
    sound project management.[Footnote 17] In response, by July 2002, DOD
    and VA had revised their strategy to pursue two initiatives: (1)
    sharing information in existing systems and (2) developing modernized
    health information systems--replacing their existing (legacy) systems--
    that would be able to share data and, ultimately, use interoperable
    electronic health records.

    In their shorter-term initiatives to share information from existing
    systems, the departments began from different positions. VA has one
    integrated medical information system--the Veterans Health Information
    Systems and Technology Architecture (VistA)--which uses all electronic
    records and was developed in-house by VA clinicians and IT personnel.
    All VA medical facilities have access to all VistA information.

    In contrast, DOD uses multiple legacy medical information systems
    (table 1 illustrates selected systems), all of which are commercial
    software products that are customized for specific uses. Until
    recently, these systems could not share information. In addition, not
    all of DOD's medical information is electronic: certain records are
    paper-based.

    Table 2: Selected DOD Legacy Medical Information Systems and Databases:

    System name: CHCS: Composite Health Care System;
    Description: Formerly DOD's primary health information system; still in
    use to capture pharmacy, radiology, and laboratory information[A].

    System name: CIS: Clinical Information System;
    Description: Commercial health information system customized for DOD;
    used by some DOD facilities for inpatients.

    System name: ICDB: Integrated Clinical Database;
    Description: Health information system used by many Air Force
    facilities.

    System name: TMDS: Theater Medical Data Store;
    Description: Database to collect electronic medical information in
    combat theater for both outpatient care and serious injuries; also
    tracks the movement of patients as they are transferred from location
    to location.

    Source: GAO analysis of DOD data.

    [A] According to DOD, CHCS applications are now accessed through its
    modernized health information system, Armed Forces Health Longitudinal
    Technology Application (AHLTA). The department no longer considers
    AHLTA as an acronym but as the official name of the system.

    [End of table]

    As we have reported,[Footnote 18] the departments' efforts to share
    information in their existing systems eventually included several
    sharing initiatives and exchange projects:

    * The Federal Health Information Exchange (FHIE), completed in 2004,
    enabled DOD to electronically transfer service members' electronic
    health information to VA when the members left active duty.

    * The Laboratory Data Sharing Interface (LDSI), a project established
    in 2004, allows DOD and VA facilities to share laboratory resources.
    This interface, now deployed at nine locations, allows the departments
    to communicate orders for lab tests and their results electronically.

    * The Bidirectional Health Information Exchange (BHIE), also
    established in 2004, was aimed at allowing clinicians at both
    departments viewable access to records on shared patients (that is,
    those who receive care from both departments--for example, veterans may
    receive outpatient care from VA clinicians and be hospitalized at a
    military treatment facility).[Footnote 19] Another benefit of the
    interface is that it allows DOD sites to see previously inaccessible
    data at other DOD sites.

    In the long term, each of the departments aims to develop a modernized
    system in the context of 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: DOD's Armed Forces Health Longitudinal Technology Application
    (AHLTA)[Footnote 20] and VA's HealtheVet. 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). For the two-way exchange of health
    information, the two repositories are to be linked through an interface
    named CHDR,[Footnote 21] which the departments began to develop in
    March 2004; implementation of the first release of the interface (at
    one site) occurred in September 2006.

    Beyond these initiatives, in January 2007, the departments announced a
    further change to their information-sharing strategy: their intention
    to jointly determine an approach for inpatient health records. On July
    31, 2007, they awarded a contract for a feasibility study and
    exploration of alternatives.[Footnote 22] According to the departments,
    one of the options would be adopting a joint solution, which would be
    expected to facilitate the seamless transition of active-duty service
    members to veteran status, and make inpatient health care data on
    shared patients more readily accessible to both DOD and VA. In
    addition, the departments believe that a joint development effort could
    enable them to realize cost savings; however, no decision on a joint
    system has yet been made. According to the departments, they expect to
    receive recommendations on possible approaches at the end of July 2008.

    In our previous work (see Related GAO Products), we pointed out that in
    view of the many tasks and challenges associated with the departments'
    long-term goal of seamless sharing of health information, it was
    essential that the departments develop a comprehensive project plan to
    guide these efforts to completion. Accordingly, in 2004, we recommended
    that the departments develop such a plan for the CHDR interface and
    that it include a work breakdown structure and schedule for all
    development, testing, and implementation tasks.[Footnote 23]
    Subsequently, the departments began work on the short-term initiatives
    described, and we raised concerns regarding how all these initiatives
    were to be incorporated into an overall strategy toward achieving the
    departments' goal of a comprehensive, seamless exchange of health
    information.

    In response to our concerns, the departments began to develop such a
    comprehensive plan, which they called the DOD/VA Information
    Interoperability Plan. To provide input to the plan and determine
    priorities, in December 2007, the departments established the Joint
    Clinical Information Board, made up of senior clinical leaders from
    both departments. The board is responsible for establishing clinical
    priorities for electronic data sharing between the departments,
    determining essential health information to be shared, and further
    identifying and prioritizing data that should be viewable and data that
    should be computable.

    The departments produced a draft DOD/VA Information Interoperability
    Plan in March 2008. According to DOD and VA officials, the draft
    defines the technical and managerial processes necessary to satisfy the
    departments' requirements and guide their activities to completion.
    According to these officials, review of this draft by senior DOD and VA
    officials is currently ongoing and is scheduled to be completed by
    August 2008.

    DOD and VA Are Currently Sharing Health Information at Different Levels
    of Interoperability, but More Work Remains to Share All Health
    Information:

    DOD and VA have established and implemented mechanisms for electronic
    sharing of health information, some of which is exchanged in computable
    form, while other information is viewable only. However, not all
    electronic health information is yet shared (for example, immunization
    records and history, data on exposure to health hazards, and
    psychological health treatment and care records). Further, although
    VA's health information is all captured electronically, not all health
    data collected by DOD are electronic--many DOD medical facilities use
    paper-based health records.

    Computable data. Data in computable form are exchanged through the CHDR
    interface, which links the modernized health data repositories for the
    new systems that each department is developing. Implementing the
    interface required the departments to agree on standards for various
    types of data, put the data into the agreed standard formats, and
    populate the repositories with the standardized data.[Footnote 24]
    Currently, the types of computable health data being exchanged are
    limited to outpatient pharmacy and drug allergy data. The next type of
    data to be standardized, included in the repositories, and exchanged is
    laboratory data.[Footnote 25]

    These data are not shared for all patients--only those who are seen at
    both DOD and VA medical facilities, identified as shared patients, and
    then "activated."[Footnote 26] Once a patient is activated, all DOD and
    VA sites can access information on that patient and receive alerts on
    allergies and drug interactions for that patient. According to DOD and
    VA officials, outpatient pharmacy and drug allergy data were being
    exchanged on more than 18,300 shared patients as of June 2008; however,
    officials stated that they are unable to track the number of shared
    patients currently receiving care from both departments, so the number
    of patients for whom data could potentially be shared is unknown.

    Viewable data. Data in viewable form are shared through the BHIE
    interface. Through BHIE, clinicians can query selected health
    information on patients from all VA and DOD sites and view current data
    onscreen almost immediately. Because the BHIE interface provides access
    to up-to-date information, the departments' clinicians expressed strong
    interest in expanding its use. As a result, the departments decided to
    broaden the capability and expand its implementation. For example, the
    departments completed a BHIE interface with DOD's Clinical Data
    Repository in July 2007, and they began sharing viewable patient vital
    signs information through BHIE in June 2008. Extending BHIE
    connectivity could provide both departments with the ability to view
    additional data in DOD's legacy systems, until such time as the
    departments' modernized systems are fully developed and implemented.
    According to a DOD/VA annual report[Footnote 27] and program officials,
    the departments now consider BHIE an interim step in their overall
    strategy to create a two-way exchange of electronic health records.

    Table 1 summarizes the types of health data currently shared via the
    departments' various initiatives (including FHIE and LDSI), as well as
    additional types of data that are currently planned for sharing.

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

    Initiative: CHDR;
    Data elements: Available: Outpatient pharmacy; Drug allergy;
    Data elements: Planned: Laboratory data;
    Interoperability level: Computable data;
    Comments: Data are exchanged between one department's data repository
    and the other's. As of June 2008, computable pharmacy and medication
    allergy data were being exchanged on over 18,300 shared patients.

    Initiative: BHIE, Bidirectional Health Information Exchange;
    Data elements: Available: Outpatient pharmacy data; Drug and food
    allergy information; Surgical pathology reports; Microbiology results;
    Cytology reports; Chemistry and hematology reports; Laboratory orders;
    Radiology text reports; Inpatient discharge summaries, emergency room
    notes, inpatient consultation, operative reports, and history and
    physical reports from CIS at 17 DOD sites (about 40% of inpatient beds)
    and all VA sites; Provider notes; Procedures; Problem lists; Vital
    signs;
    Data elements: Planned: Scanned images and documents; Family history;
    Social history; Other history questionnaires; Radiology images;
    Psychological health treatment and care records; Rollout of CIS at
    additional DOD sites; expansion to include additional CIS
    documentation: initial evaluation notes, procedure notes, evaluation
    and management notes, preoperative and postoperative evaluation notes;
    Interoperability level: Structured, viewable data; Unstructured,
    viewable data from scanned documents;
    Comments: Data are not transferred but can be viewed; Limitations:
    Inpatient data are available only from a portion of DOD inpatient
    hospitals, not all military hospitals.

    Initiative: FHIE, Federal Health Information Exchange;
    Data elements: Available: Patient demographics; Laboratory results;
    Radiology reports; Outpatient pharmacy information; Admission discharge
    transfer data; Discharge summaries from CHCS[A]; Consult reports;
    Allergies; Data from the DOD Standard Ambulatory Data Record; Pre-and
    postdeployment health assessments; Postdeployment health reassessments;
    Data elements: Planned: None;
    Interoperability level: Structured, viewable data;
    Comments: Noncomputable text data are transferred to VA and stored in
    VA's FHIE database, making it accessible to all VA clinicians; One-way
    batch transfer of text data from DOD to VA occurs weekly if discharged
    patient has been referred to VA for treatment; otherwise monthly;
    Limitations: Discharge summaries from CHCS only[A] are transferred, not
    from other DOD systems (see table 2).

    Initiative: LDSI, Laboratory Data Sharing Interface;
    Data elements: Available: Laboratory orders; Laboratory results
    (chemistry, hematology, toxicology, and serology at all LDSI sites;
    anatomic pathology and microbiology at two localities);
    Data elements: Planned: Additional sites as business need arises;
    Interoperability level: Structured, viewable data;
    Comments: Noncomputable text data are transferred and captured in the
    individual's health record.

    Source: GAO analysis of VA and DOD data.

    [A] According to department officials, the discharge summary module of
    CHCS is used at a limited number of sites.

    [End of table]

    As depicted in table 3, DOD and VA are sharing or plan to share a wide
    range of health information; however, other health information that the
    departments currently capture has not yet been addressed (for example,
    immunization records and history and data on exposure to health
    hazards). Further, although VA's health information is all captured
    electronically, many DOD medical facilities continue to rely on paper
    records. Also, clinical encounters for those enrolled in the military's
    TRICARE health care program[Footnote 28] are not captured in DOD's
    electronic health system unless care is received at a military
    treatment facility.[Footnote 29]

    According to the departments' officials, the DOD/VA Information
    Interoperability Plan (targeted for approval in August 2008) is to
    address these and other issues and define tasks required to guide the
    development and implementation of interoperable, bidirectional, and
    standards-based electronic health records and capabilities for military
    and veteran beneficiaries. DOD and VA are in the process of finalizing
    the plan, and we have not yet performed an assessment. However, if it
    includes the essential elements needed to guide the departments in
    achieving their long-term goal of seamless sharing of health
    information, it could improve the prospects for the successful
    achievement of this goal.

    DOD and VA Have Adopted Standards to Allow Sharing and Are Taking Steps
    to Follow Federal Standards, Which Continue to Evolve:

    DOD and VA have agreed upon numerous common standards that allow them
    to share health data, which include standards that are part of current
    and emerging federal interoperability specifications. The foundation
    built by this collaborative process has allowed DOD and VA to begin
    sharing computable health data (the highest level of interoperability).
    Continuing their historical involvement in efforts to agree upon
    standards for the electronic exchange of clinical health information,
    the departments are also participating in recent ongoing standards-
    related initiatives led by the Office of the National Coordinator for
    Health Information Technology (within the Department of Health and
    Human Services). In addition, DOD is taking steps to arrange for
    certification of its modernized health information system (a customized
    commercial system) against current standards.

    The standards agreed to by the two departments are listed in a jointly
    published common set of interoperability standards called the Target
    DOD/VA Health Standards Profile. This profile resulted from an effort
    that took place beginning in 2001, in which the two departments
    compared their individual standards profiles for compatibility and
    began converging them. First developed in 2004, the Target Standards
    Profile is updated annually and is used for reviewing joint DOD/VA
    initiatives to ensure standards compliance. According to the
    departments, they anticipate continued updates and revisions to the
    Target Standards Profile as additional federal standards emerge and are
    in varying stages of recognition and acceptance by HHS (as previously
    presented in table 1).

    The current version of the profile, dated September 2007, includes
    federal standards (such as data standards established by the Food and
    Drug Administration and security standards established by the National
    Institute of Standards and Technology); industry standards (such as
    wireless communications standards established by the Institute of
    Electrical and Electronics Engineers and Web file sharing standards
    established by the American National Standards Institute); and
    international standards (such as SNOMED CT, which was mentioned
    earlier, and security standards established by the International
    Organization for Standardization). The profile also indicates which of
    these standards support the HHS-recognized use cases and HITSP
    interoperability specifications. For example, for clinical data on
    allergy reactions, the departments agreed to use SNOMED CT codes
    (mentioned previously), which are included as part of HITSP
    interoperability specifications.

    In particular, for the two kinds of data now being exchanged in
    computable form through CHDR (pharmacy and allergy data), DOD and VA
    adopted National Library of Medicine data standards for medications and
    drug allergies,[Footnote 30] as well as SNOMED CT codes for allergy
    reactions. According to officials, the departments rely on published
    versions of the library standards, and they can also submit new terms
    to the National Library of Medicine for inclusion in the standards.
    Also, the departments can exchange a standardized allergy reaction as
    long as it is mapped to a SNOMED CT code in each department's allergy
    reaction file. If a coded term is not available in the files,
    clinicians can exchange descriptions of allergy reactions in free text.
    This standardization was a prerequisite for exchanging computable
    medical information--an accomplishment that, according to the National
    Coordinator for Health IT, has not yet been achieved in any other
    sector.

    Continuing the departments' historical involvement in efforts to agree
    upon standards for the electronic exchange of clinical health
    information, health officials from both DOD and VA participate as
    members of the American Health Information Community and HITSP. For
    example, the 18-member community includes high-level representatives
    from both DOD (the Assistant Secretary of Defense for Health Affairs)
    and VA (the Director, Health Data and Informatics, Veterans Health
    Administration). DOD and VA are members of the HITSP Board and are
    actively working on several committees and groups (Provider Perspective
    Technical Committee; Population Perspective Technical Committee;
    Security, Privacy and Infrastructure Domain Technical Committee; Care
    Management and Health Records Domain Technical Committee;
    Administrative and Financial Domain Technical Committee; Harmonization
    Committee; and Foundation Committee). The National Coordinator
    indicated that such participation is important and stated that it would
    not be advisable for DOD and VA to move significantly ahead of the
    national standards initiative; if they did, the departments might have
    to change the way their systems share information by adjusting them to
    the national standards later, as the standards continue to evolve.

    In addition, according to DOD officials, the department is taking steps
    to ensure that the electronic health records produced by its modernized
    health information system, AHLTA, which is a customized commercial
    software application, are compliant with standards by arranging for
    certification through the Certification Commission for Healthcare
    Information Technology. Specifically, version 3.3 of AHLTA, which is
    still undergoing beta testing,[Footnote 31] was conditionally certified
    in April 2007 against 2006 outpatient electronic health record criteria
    established by the commission. DOD officials stated that AHLTA version
    3.3 has been installed at three DOD locations[Footnote 32] for beta
    testing and has met specific functionality, interoperability, and
    security requirements. The commission cannot fully certify this version
    of AHLTA until it has verified that the system has been in operational
    use at a medical site.

    The departments' efforts to share data and to be involved in
    standardization activities are important mechanisms for ensuring that
    their electronic health records are both interoperable and aligned with
    emerging standards and specifications.

    DOD and VA Have Taken Steps to Establish the Joint Interagency Program
    Office, but the Office Does Not Yet Have Permanent Leadership, Staff,
    or Facilities:

    To accelerate the departments' ongoing interoperability efforts,
    Congress included provisions establishing a joint interagency program
    office in the National Defense Authorization Act for Fiscal Year 2008.
    Under the act, the Secretary of Defense and the Secretary of Veterans
    Affairs were required to jointly develop schedules and benchmarks for
    setting up the DOD/VA Interagency Program Office, as well as for other
    activities for achieving interoperable health information (that is,
    establishing system requirements, acquisition and testing, and
    implementation of interoperable electronic health records or
    capabilities). The schedules and benchmarks were due 30 days after
    passage of the act (February 28, 2008).

    The departments developed a draft implementation plan defining fiscal
    years 2008 and 2009 schedules and milestones; the date of the draft was
    April 25--almost 2 months after the due date. In the effort to set up
    the program office, the departments appointed an Acting Director from
    DOD and an Acting Deputy Director from VA on April 17, 2008.[Footnote
    33] According to the Acting Director, they have also detailed staff and
    provided temporary space and equipment to a transition team.

    According to this official, through the efforts of the transition team,
    the departments are currently developing a charter for the office,
    defining and approving an organizational structure, and preparing to
    begin recruiting permanent staff for the office, who are expected to
    number about 30. According to the implementation plan, the departments
    expect to appoint a permanent Director and Deputy and begin recruiting
    staff by October 2008. According to the Acting Director, program staff
    are expected to be in place, and the office is expected to be fully
    operational by December 2008. According to the departments, $4.94
    million was requested to fund the office for fiscal year 2008, which is
    expected to be received this July. Funding requirements of $6.94
    million for fiscal year 2009 were submitted in June.

    The draft implementation plan includes schedules and milestones for
    achieving interoperable health information in two stages. The first
    stage--Interoperability I, to be completed by September 2008--is to
    address those health data most commonly required by health care
    providers, as validated by the Joint Clinical Information
    Board.[Footnote 34] The first milestone for Interoperability I, sharing
    vital signs information, has been achieved. The remaining milestones
    (sharing questionnaires and forms, family history, social history, and
    other history) are all due September 2008.

    The second stage--Interoperability II, to be completed by September
    2009--is to address additional health information enhancements.
    However, the information to be covered by these enhancements has not
    yet been fully defined, and milestone dates are not fully established:

    * According to the plan, the requirements for the Interoperability II
    enhancements are to be validated by the Joint Clinical Information
    Board, which sets the clinical priorities for what electronic health
    information should be shared next. This validation, followed by
    approval by senior department leadership, was to be complete by June
    2008. However, according to department officials, the completion date
    is now expected to be the end of July 2008.

    * Of 52 milestone dates for Interoperability II, 19 are yet to be
    determined. For example, milestone dates have not been identified
    regarding capabilities to share data on exposures to health hazards,
    immunization records and history, family history, and psychological
    health treatment and care records.

    Officials stated that decisions on these milestone dates will depend on
    clinical priorities, technical considerations, and policy decisions.
    For example, the exchange of psychological health treatment and care
    records requires policy decisions regarding appropriate access.
    Further, according to the implementation plan draft, the plan is
    intended to serve as a "living document" that will be updated and
    refined as more detailed information becomes known on planned fiscal
    year 2008 and fiscal year 2009 initiatives, and as health care
    information needs change.

    According to the Acting Director, the draft implementation plan has not
    been finalized because of remaining uncertainties regarding such issues
    as space and staffing needs. For example, although the scope of the
    office's responsibility is to be for electronic health records and
    capabilities, the departments' leadership may broaden its scope to
    include sharing of personnel and benefits data, which would affect the
    number of staff required. However, although the implementation plan (as
    a planning tool) is appropriately a living document, it is nonetheless
    important to complete the planning and make the decisions needed to
    finalize the initial plan, particularly in view of the fast approaching
    September 2009 deadline.

    Further, according to department officials, the joint interagency
    program office will play a crucial role in coordinating the
    departments' efforts to accelerate their interoperability efforts. An
    important aspect of this coordination will be managing the further
    development and implementation of the DOD/VA Information
    Interoperability Plan, currently under review by senior management.
    According to these officials, having a centralized office to take on
    this role will be a primary benefit. However, the effort to set up the
    program office is still in its early stages. The positions of Director
    and Deputy Director are not yet permanently filled, permanent staff
    have not yet been hired, and facilities have not yet been designated
    for housing the office. Until the program office is fully established,
    it will not be able to play this crucial role effectively.

    Conclusions:

    DOD and VA are currently sharing more health information than ever
    before, including exchanging some at the highest level of
    interoperability, that is, in computable form. The departments also
    have efforts under way to share additional information. Additional
    issues remaining to be addressed include electronic sharing of the
    information in paper-based health records and the completion of their
    long-range plans to develop fully interoperable health information
    systems. According to the departments, the DOD/VA Information
    Interoperability Plan is to address these and other issues. Once the
    plan is finalized and approved by DOD and VA officials, we intend to
    perform an assessment of the plan. However, if the plan includes the
    essential elements needed to guide the departments in achieving their
    long-term goal of seamless sharing of health information, it could
    improve the prospects for the successful achievement of this goal.

    Further enhancing interoperability depends on adherence to common
    standards. The two departments have agreed on standards and are working
    with each other and federal groups to help ensure that their systems
    are both interoperable and compliant with current and emerging federal
    standards.

    The joint interagency program office is to play a crucial role in
    accelerating the departments' efforts to achieve electronic health
    records and capabilities that allow for full interoperability. However,
    it is not expected to be fully set up until the end of the year, after
    which only 9 months will remain to meet the goal of full
    interoperability between the departments by September 2009. The
    implementation plan, which was almost 2 months late, remains in draft,
    with many milestone dates yet to be determined. In view of the short
    timeframes, without a fully established program office and a finalized
    implementation plan with set milestones, the departments may be
    challenged in meeting the required date for achieving interoperable
    electronic health records and capabilities.

    Recommendations for Executive Action:

    To better ensure that the effort by DOD and VA to achieve fully
    interoperable electronic health record systems or capabilities is
    accelerated, we recommend that the Secretaries of Defense and Veterans
    Affairs give priority to fully establishing the Joint Interagency
    Program Office by expediting efforts to:

    * put in place permanent leadership, staff, and facilities and:

    * make the necessary decisions to finalize the draft implementation
    plan.

    Agency Comments and Our Evaluation:

    In providing written comments on a draft of this report, the Assistant
    Secretary of Defense for Health Affairs and the Secretary of Veterans
    Affairs agreed with our recommendations. (The departments' comments are
    reproduced in app.II and app. III, respectively.) DOD stated that high
    priority will be given to fully establishing the Joint Interagency
    Program Office, with specific focus on expanding efforts related to
    permanent leadership, staff, and facilities. DOD also provided
    technical comments on the draft report, which we incorporated as
    appropriate.

    VA's comments described actions planned or being taken that respond to
    our recommendations. For example, according to VA, the Deputy Director
    of the Interagency Program Office is expected to be appointed by
    October 2008. In addition, VA stated that the departments
    collaboratively determined the number and type of staff required for
    the new office and expect to hire permanent staff by December 2008. In
    this regard, DOD has taken the lead on securing permanent facilities
    for the program office and is currently working with the General
    Services Administration to find suitable space. In addition, VA stated
    the departments are in the process of finalizing the implementation
    plan and that by October 31, 2008, they expect to identify the
    milestones and timelines for defining requirements to support
    interoperable health records. The department noted that the Joint
    Clinical Information Board is expected to identify, by July 31, 2008,
    the specific data types and format for sharing that must be achieved by
    September 2009. If the actions planned or currently under way are
    properly implemented, they should help ensure that DOD and VA will be
    successful in meeting their goals for sharing interoperable health
    information.

    We are sending copies of this report to the Secretaries of Veterans
    Affairs and Defense, appropriate congressional committees, and other
    interested parties. We will also make copies available to others upon
    request. In addition, the report is available at no charge on the GAO
    Web site at [hyperlink, http://www.gao.gov].

    If you or your staffs have questions about this report, please contact
    me at (202) 512-6304 or melvinv@gao.gov. Contact points for our Offices
    of Congressional Relations and Public Affairs may be found on the last
    page of this report. Key contributors to this report are listed in
    appendix IV.

    Signed by:
    Valerie C. Melvin:
    Director, Human Capital and Management Information Systems Issues:

    List of Congressional Committees:

    The Honorable Daniel K. Inouye:
    Chairman:
    The Honorable Ted Stevens:
    Ranking Member:
    Subcommittee on Defense:
    Committee on Appropriations:
    United States Senate:

    The Honorable John P. Murtha:
    Chairman:
    The Honorable C.W. Bill Young:
    Ranking Member:
    Subcommittee on Defense:
    Committee on Appropriations:
    United States House of Representatives:

    The Honorable Tim Johnson:
    Chairman:
    The Honorable Kay Bailey Hutchison:
    Ranking Member:
    Subcommittee on Military Construction, Veterans' Affairs, and Related
    Agencies:
    Committee on Appropriations:
    United States Senate:

    The Honorable Chet Edwards:
    Chairman:
    The Honorable Zach Wamp:
    Ranking Member:
    Subcommittee on Military Construction, Veterans' Affairs, and Related
    Agencies:
    Committee on Appropriations:
    United States House of Representatives:

    The Honorable Carl Levin:
    Chairman:
    The Honorable John McCain:
    Ranking Member:
    Committee on Armed Services:
    United States Senate:

    The Honorable Ike Skelton:
    Chairman:
    The Honorable Duncan Hunter:
    Ranking Member:
    Committee on Armed Services:
    United States House of Representatives:

    The Honorable Daniel K. Akaka:
    Chairman:
    The Honorable Richard M. Burr:
    Ranking Member:
    Committee on Veterans' Affairs:
    United States Senate:

    The Honorable Bob Filner:
    Chairman:
    The Honorable Steve Buyer:
    Ranking Member:
    Committee on Veterans' Affairs:
    United States House of Representatives:

    [End of section]

    Appendix I: Scope and Methodology:

    To describe the progress of the Department of Defense (DOD) and
    Department of Veterans Affairs (VA) to date on developing electronic
    health records systems or capabilities that allow for full
    interoperability of personal health care information between the
    departments, we reviewed our previous work on DOD and VA efforts to
    develop health information systems, interoperable health records, and
    interoperability standards to be implemented in federal health care
    programs. Additionally, we reviewed information gathered from agency
    documentation and interviews with cognizant DOD and VA officials
    relating to the departments' efforts to share electronic health
    information. Further, we visited a DOD military treatment facility and
    a VA medical center (Walter Reed Army Medical Center and the
    Washington, D.C., VA Medical Center), chosen because they were
    accessible and allowed us to observe the sharing capabilities and
    functionality of the two departments' electronic health information
    systems.

    To describe steps taken by the departments to ensure that their health
    records comply with applicable interoperability standards,
    implementation specifications, and certification criteria of the
    federal government, we analyzed information gathered from DOD and VA
    documentation and interviews pertaining to the interoperability
    standards and implementation specifications that the two departments
    have agreed to for exchanging health information via their health care
    information systems. We reviewed documentation and interviewed agency
    officials from the Department of Health and Human Services' Office of
    the National Coordinator for Health Information technology to obtain
    information regarding the defined federal interoperability standards,
    implementation specifications, and certification criteria. We also
    reviewed documentation and interviewed DOD and VA officials from the
    Joint Clinical Information Board to determine the extent to which the
    departments have adopted federal interoperability standards,
    implementation specifications, and certification criteria.

    To describe efforts to set up the joint interagency program office, we
    analyzed documentation regarding the establishment of the office and
    interviewed responsible officials.

    We conducted this performance audit at VA and DOD sites in the greater
    Washington, D.C., metropolitan area from March 2008 through July 2008
    in accordance with generally accepted government auditing standards.
    Those standards require that we plan and perform the audit to obtain
    sufficient, appropriate evidence to provide a reasonable basis for our
    findings and conclusions based on our audit objectives. We believe that
    the evidence obtained provides a reasonable basis for our findings and
    conclusions based on our audit objectives.

    [End of section]

    Appendix II: Comments from the Department of Defense:

    The Assistant Secretary Of Defense:
    1200 Defense Pentagon:
    Washington, DC 20301-1200:

    July 22, 2008:

    Ms. Valerie C. Melvin:
    Director, Human Capital and Management Information Systems Issues:
    U.S. Government Accountability Office:
    441 G Street, N.W.
    Washington, DC 20548:

    Dear Ms. Melvin:

    This is the Department of Defense's (DoD) response to the
    recommendations enclosed in the Government Accountability Office (GAO)
    Draft Report, "Electronic Health Records: DOD and VA Have Increased
    Their Sharing of Health Information, but More Work Remains," dated July
    14, 2008 (GAO-08-954).

    DoD acknowledges receipt of the draft audit report and concurs with the
    overall findings and recommendations. We have provided several
    suggested technical corrections in the enclosed formal response-
    Thank you for the opportunity to review and comment on the draft
    report. My points of contact for additional information are Ms. Lois
    Kellett, who may be reached at, (703) 681-9530, or
    Lois.Kellett@tma.osd.mil, and Mr. Gunther Zimmerman, who may be reached
    at, (703) 681-4360, or Gunther.Zimmerman@tma.osd.mil.

    Sincerely,

    Signed by: Stephen L. Jones, for:
    S. Ward Casscells, MD:

    Enclosure: As stated:

    Government Accountability Office Draft Report-Dated July 14, 2008
    "Electronic Health Records: DOD and VA Have Increased Their Sharing Of
    Health Information, But More Work Remains" (Project No. GAO-08-954):

    Department of Defense Concurrence:

    Recommendation 1: The Government Accountability Office (GAO)
    recommended that the Secretary of Defense give priority to fully
    establishing the Joint Interagency Program Office by expanding efforts
    to put in place permanent leadership, staff, and facilities. (p. 31/GAO
    Draft Report)

    DoD Response: Concur. The Department of Defense (DoD) will continue to
    give high priority to fully establishing the Joint Interagency Program
    Office, with specific focus on expanding efforts related to permanent
    leadership, staff, and facilities.

    Recommendation 2: The GAO recommended that the Secretary of Defense
    give priority to fully establishing the Joint Interagency Program
    Office by expanding efforts to make the necessary decisions to finalize
    the draft implementation plan. (p. 32/GAO Draft Report)

    DoD Response: Concur. DoD will give high priority to fully establishing
    the Joint Interagency Program Office, with specific focus on expanding
    efforts to make the necessary decisions to finalize the draft
    implementation plan.

    [End of section]

    Appendix III: Comments from the Department of Veterans Affairs:

    The Secretary Of Veterans Affairs:
    Washington:

    July 18, 2008:

    Ms. Valerie Melvin:
    Director:
    Information Technology:
    U.S. Government Accountability Office:
    441 G Street, NW:
    Washington, DC 20548:

    Dear Ms. Melvin:

    The Department of Veterans Affairs (VA) has reviewed your draft report,
    Electronic Health Records: DOD and VA Have Increased Their Sharing of
    Health Information, but More Work Remains (GAO-08-954), and agrees with
    its conclusions and concurs with its recommendations.

    VA and the Department of Defense (DoD) have made significant progress
    in complying with the requirements of the National Defense
    Authorization Act of Fiscal Year 2008- The Interagency Program Office
    (IPO) was established, and an Acting Director and Deputy Director were
    appointed, temporary staff has been detailed to the office and
    temporary space and equipment have been provided. VA expects to appoint
    a permanent Deputy Director by October 2008, and hire permanent program
    staff by December 2008- On April 25, 2008, the IPO submitted to
    Congress a draft Implementation Plan discussing planned activities to
    achieve interoperable health records by September 2009.

    Although we have made significant progress to date, VA acknowledges
    that there are difficult challenges ahead of us. VA and DoD leadership
    remain committed to the sharing of electronic health information and
    fully expects to achieve this objective by September 2009.

    The enclosure addresses GAO's recommendations. VA appreciates the
    opportunity to comment on your draft report.

    Sincerely yours,

    Signed by:

    James B. Peake, M.D.

    Enclosure:

    Department of Veterans Affairs (VA) Comments to Government
    Accountability Office (GAO) Draft Report, Electronic Health Records:
    DOD and VA Have Increased Their Sharing of Health Information, but More
    Work Remains (GAO-08-954):

    To better ensure that the effort by DOD and VA to achieve fully
    interoperable electronic health record systems or capabilities is
    accelerate, GAO recommend that the Secretaries of Defense and Veterans
    Affairs give priority to fully establishing the Joint Interagency
    Program Office by expediting efforts to:

    * Put in place permanent leadership, staff, and facilities.

    Concur - Under the National Defense Authorization Act of Fiscal year
    2008 the Secretary of Defense and the Secretary of Veterans Affairs
    were required to jointly develop schedules and benchmarks for setting
    up the Department of Defense (DoD)/Department of Veterans Affairs (VA)
    Interagency Program Office (IPO). VA/DoD developed a draft
    implementation plan defining fiscal year 2008 and 2009 schedules and
    milestones. In the effort to set up the IPO, VA/DoD appointed an Acting
    Director from DoD and an Acting Deputy Director from VA on April 17,
    2008- VA/DoD have detailed temporary staff and provided temporary space
    and equipment.

    In order to fully implement the IPO, VA/DoD considered several key
    decisions regarding permanent the IPO structure and scope. The IPO was
    placed under the governance of the DoD/VA Joint Executive Council.
    VA/DoD have also agreed to what the IPO scope of responsibilities
    should be over the next 9 to 12 months. These key decisions enabled the
    departments to complete staffing plans and conduct physical space
    planning for the permanent IPO structure.

    To date, the departments have completed and approved a staffing plan
    and staff organization chart. VA and DoD worked collaboratively to
    determine the number and type of staff required to man this new office
    and have developed position descriptions. Those position descriptions
    were submitted to the human resources office at the end of June- Human
    Resources is classifying the position and once complete will issue job
    announcements. VA anticipates that the positions will be approved for
    hiring actions no later than August 2008. VA expects to appoint a
    permanent Deputy Director by October 2008, and hire permanent program
    staff by December 2008.

    Once the staff issues (as to numbers and types) had been dealt with
    then the space requirement could be developed. DoD has taken the lead
    on securing the permanent facilities to house the new program office
    and are currently working with the General Services Administration to
    find suitable space.

    The IPO meets three times every week and has established a standing
    agenda that includes tracking hiring actions, locating permanent
    physical space for the IPO, and development of key IPO documents.

    * Make the necessary decisions to finalize the draft implementation
    plan.

    Concur - The purpose of the DoD/VA Information Interoperability Plan
    (targeted for approval in August 2008) is to define tasks required to
    guide the development and implementation of interoperable,
    bidirectional, and standards-based electronic health records and
    capabilities for military and veteran beneficiaries. DoD and VA are in
    the process of finalizing the plan.

    On April 25, 2008, the IPO submitted to Congress a draft Implementation
    Plan discussing planned activities to achieve interoperable health
    records by September 2009. VA/DoD have formed the Joint Clinical
    Information Board (JCIB) to ensure that clinicians treating patients
    determine the key information that must be interoperable by September
    2009. The JCIB has validated that the information currently shared
    meets the Dole-Shalala target to share essential information in
    viewable format. Additionally, VA and DoD anticipate that by July 31,
    2008, the JCIB will have identified the specific data types and format
    for sharing that must be achieved by September 2009 for interoperable
    electronic health records. By August 31, 2008, VA and DoD will obtain
    formal approval from the Health Executive Council on the data elements
    identified by the JCIB. By October 31, 2008, VA and DoD will identify
    the milestones and timelines for requirements definition to support
    interoperable health records. The JCIB's findings and subsequent
    requirements activities will be used to update the Implementation Plan-
    The JCIB has determined that not all information needs to be shared in
    computable format. JCIB is determining what must be computable and what
    will be shared beyond September 2009 and this will provide the
    framework for completion of the Implementation Plan.

    VA/DoD will meet the target identified by the Dole-Shalala commission
    to share essential health information in viewable format by October
    2008 when we begin sharing family and social history information on
    patients. Essential health information currently shared includes
    outpatient pharmacy and allergy information, outpatient and inpatient
    laboratory orders and results, radiology reports, progress reports and
    inpatient information such as discharge summaries, operative reports
    and consults from key DoD military treatment facilities, and vital
    signs. DoD also sends clinical theater information which is available
    to all VA hospitals and scanned inpatient records and radiology images
    from key military treatment facilities to the VA polytrauma centers. VA
    and DoD are working on expanding a bidirectional image sharing pilot
    and are finalizing an enterprise-wide plan for sharing images that will
    be delivered on October 2008.

    [End of section]

    Appendix IV: GAO Contact and Staff Acknowledgments:

    GAO Contact:

    Valerie C. Melvin, (202) 512-6304 or melvinv@gao.gov:

    Staff Acknowledgments:

    In addition to the contact named above, key contributions were made to
    this report by Barbara S. Oliver (Assistant Director), Barbara Collier,
    Kelly Shaw, and Robert Williams, Jr.

    [End of section]

    Related GAO Products:

    VA and DOD Health Care: Progress Made on Implementation of 2003
    President's Task Force Recommendations on Collaboration and
    Coordination, but More Remains to Be Done. [hyperlink,
    http://www.gao.gov/cgi-bin/getrpt?GAO-08-495R]. Washington, D.C.: April
    30, 2008.

    Health Information Technology: HHS Is Pursuing Efforts to Advance
    Nationwide Implementation, but Has Not Yet Completed a National
    Strategy. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-499T].
    Washington, D.C.: February 14, 2008.

    Information Technology: VA and DOD Continue to Expand Sharing of
    Medical Information, but Still Lack Comprehensive Electronic Medical
    Records. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-207T].
    Washington, D.C.: October 24, 2007.

    Veterans Affairs: Progress Made in Centralizing Information Technology
    Management, but Challenges Persist. [hyperlink, http://www.gao.gov/cgi-
    bin/getrpt?GAO-07-1246T]. Washington, D.C.: September 19, 2007.

    Information Technology: VA and DOD Are Making Progress in Sharing
    Medical Information, but Remain Far from Having Comprehensive
    Electronic Medical Records. [hyperlink, http://www.gao.gov/cgi-
    bin/getrpt?GAO-07-1108T]. Washington, D.C.: July 18, 2007.

    Health Information Technology: Efforts Continue but Comprehensive
    Privacy Approach Needed for National Strategy. [hyperlink,
    http://www.gao.gov/cgi-bin/getrpt?GAO-07-988T]. Washington, D.C.: June
    19, 2007.

    Information Technology: VA and DOD Are Making Progress in Sharing
    Medical Information, but Are Far from Comprehensive Electronic Medical
    Records. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-852T].
    Washington, D.C.: May 8, 2007.

    DOD and VA Outpatient Pharmacy Data: Computable Data Are Exchanged for
    Some Shared Patients, but Additional Steps Could Facilitate Exchanging
    These Data for All Shared Patients. [hyperlink, http://www.gao.gov/cgi-
    bin/getrpt?GAO-07-554R]. Washington, D.C.: April 30, 2007.

    Health Information Technology: Early Efforts Initiated but
    Comprehensive Privacy Approach Needed for National Strategy.
    [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-400T]. Washington,
    D.C.: February 1, 2007.

    Health Information Technology: Early Efforts Initiated, but
    Comprehensive Privacy Approach Needed for National Strategy.[hyperlink,
    http://www.gao.gov/cgi-bin/getrpt?GAO-07-238]. Washington, D.C.:
    January 10, 2007.

    Health Information Technology: HHS is Continuing Efforts to Define Its
    National Strategy. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-06-
    1071T]. Washington, D.C.: September 1, 2006.

    Information Technology: VA and DOD Face Challenges in Completing Key
    Efforts. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-06-905T].
    Washington, D.C.: June 22, 2006.

    Health Information Technology: HHS Is Continuing Efforts to Define a
    National Strategy. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-06-
    346T]. Washington, D.C.: March 15, 2006.

    Computer-Based Patient Records: VA and DOD Made Progress, but Much Work
    Remains to Fully Share Medical Information. [hyperlink,
    http://www.gao.gov/cgi-bin/getrpt?GAO-05-1051T]. Washington, D.C.:
    September 28, 2005.

    Health Information Technology: HHS Is Taking Steps to Develop a
    National Strategy. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-05-
    628]. Washington, D.C.: May 27, 2005.

    Computer-Based Patient Records: VA and DOD Efforts to Exchange Health
    Data Could Benefit from Improved Planning and Project Management.
    [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-04-687]. Washington,
    D.C.: June 7, 2004.

    Computer-Based Patient Records: Improved Planning and Project
    Management Are Critical to Achieving Two-Way VA-DOD Health Data
    Exchange. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-04-811T].
    Washington, D.C.: May 19, 2004.

    Computer-Based Patient Records: Sound Planning and Project Management
    Are Needed to Achieve a Two-Way Exchange of VA and DOD Health Data.
    [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-04-402T]. Washington,
    D.C.: March 17, 2004.

    Computer-Based Patient Records: Short-Term Progress Made, but Much Work
    Remains to Achieve a Two-Way Data Exchange Between VA and DOD Health
    Systems. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-04-271T].
    Washington, D.C.: November 19, 2003.

    VA Information Technology: Management Making Important Progress in
    Addressing Key Challenges. [hyperlink, http://www.gao.gov/cgi-
    bin/getrpt?GAO-02-1054T]. Washington, D.C.: September 26, 2002.

    Veterans Affairs: Sustained Management Attention Is Key to Achieving
    Information Technology Results. [hyperlink, http://www.gao.gov/cgi-
    bin/getrpt?GAO-02-703]. Washington, D.C.: June 12, 2002.

    VA Information Technology: Progress Made, but Continued Management
    Attention Is Key to Achieving Results. [hyperlink,
    http://www.gao.gov/cgi-bin/getrpt?GAO-02-369T]. Washington, D.C.: March
    13, 2002.

    VA and Defense Health Care: Military Medical Surveillance Policies in
    Place, but Implementation Challenges Remain. [hyperlink,
    http://www.gao.gov/cgi-bin/getrpt?GAO-02-478T]. Washington, D.C.:
    February 27, 2002.

    VA and Defense Health Care: Progress Made, but DOD Continues to Face
    Military Medical Surveillance System Challenges. [hyperlink,
    http://www.gao.gov/cgi-bin/getrpt?GAO-02-377T]. Washington, D.C.:
    January 24, 2002.

    VA and Defense Health Care: Progress and Challenges DOD Faces in
    Executing a Military Medical Surveillance System. [hyperlink,
    http://www.gao.gov/cgi-bin/getrpt?GAO-02-173T]. Washington, D.C.:
    October 16, 2001.

    Computer-Based Patient Records: Better Planning and Oversight by VA,
    DOD, and IHS Would Enhance Health Data Sharing. [hyperlink,
    http://www.gao.gov/cgi-bin/getrpt?GAO-01-459]. Washington, D.C.: April
    30, 2001.

    [End of section]

    Footnotes:

    [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 August 1998, issued a directive requiring VA and DOD to
    develop a "computer-based patient record system that will accurately
    and efficiently exchange information."

    [2] We recently testified that DOD and VA have only partially achieved
    the goal of developing interoperable electronic health records. GAO,
    Information Technology: VA and DOD Continue to Expand Sharing of
    Medical Information, but Still Lack Comprehensive Electronic Medical
    Records, [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-207T]
    (Washington, D.C.: Oct. 24, 2007).

    [3] The commission recommended that DOD and VA work toward a "fully
    interoperable information system that will meet the long-term
    administrative and clinical needs of all military personnel over time."

    [4] The National Defense Authorization Act for Fiscal Year 2008, Pub.
    L. No. 110-181, Section 1635, required "Fully Interoperable Electronic
    Personal Health Information for the Department of Defense and the
    Department of Veterans Affairs."

    [5] Interoperability is the ability of two or more systems or
    components to exchange information and to use the information that has
    been exchanged. Further discussion of levels of interoperability is
    provided later in this report.

    [6] See Related GAO Products at the end of this report for previous GAO
    reports and testimonies on DOD/VA health information sharing and
    national health information technology issues.

    [7] These initiatives include identifying relevant existing standards,
    identifying overlaps and gaps in the standards, developing
    recommendations to address overlaps and gaps, and developing
    interoperability specifications and certification criteria based on
    these standards.

    [8] GAO, Health Information Technology: HHS Is Pursuing Efforts to
    Advance Nationwide Implementation, but Has Not Yet Completed a National
    Strategy, [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-499T]
    (Washington, D.C.: Feb. 14, 2008).

    [9] An electronic health record is a longitudinal collection of
    information about the health of an individual or the care provided,
    such as patient demographics, progress notes, problems, medications,
    vital signs, past medical history, immunizations, laboratory data, and
    radiology reports.

    [10] Executive Order 13335, Incentives for the Use of Health
    Information Technology and Establishing the Position of the National
    Health Information Technology Coordinator (Washington, D.C.: Apr. 27,
    2004).

    [11] Use cases are descriptions of events that detail what a system (or
    systems) needs to do to achieve a specific mission or goal; they convey
    how individuals and organizations (actors) interact with the systems.
    For health IT, use cases strive to provide enough detail and context
    for follow-up activities to occur, such as standards harmonization,
    architecture specification, certification consideration, and detailed
    policy discussions to advance the national health IT agenda.

    [12] The American National Standards Institute is a private, nonprofit
    organization whose mission is to promote and facilitate voluntary
    consensus standards and ensure their integrity.

    [13] IS 01, Interoperability Specification for Electronic Health Record
    Laboratory Results Reporting.

    [14] SNOMED CT, a comprehensive health and clinical terminology, was
    established by the International Health Terminology Standards
    Development Organisation, a not-for-profit association that develops
    and promotes use of SNOMED CT so as to support safe and effective
    health information exchange.

    [15] [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-499T].

    [16] GAO, Health Information Technology: HHS Is Taking Steps to Develop
    a National Strategy, [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-
    05-628] (Washington, D.C.: May 27, 2005). See also Related GAO Products
    at the end of this report.

    [17] GAO, Computer-Based Patient Records: Better Planning and Oversight
    by VA, DOD, and IHS Would Enhance Health Data Sharing, [hyperlink,
    http://www.gao.gov/cgi-bin/getrpt?GAO-01-459] (Washington, D.C.: Apr.
    30, 2001) and Veterans Affairs: Sustained Management Attention Is Key
    to Achieving Information Technology Results, [hyperlink,
    http://www.gao.gov/cgi-bin/getrpt?GAO-02-703] (Washington, D.C.: June
    12, 2002).

    [18] GAO, Information Technology: VA and DOD Are Making Progress in
    Sharing Medical Information, but Are Far from Comprehensive Electronic
    Medical Records, [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-
    852T] (Washington, D.C.: May 8, 2007); and [hyperlink,
    http://www.gao.gov/cgi-bin/getrpt?GAO-08-207T].

    [19] 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
    interface allows clinicians in both departments to view, in real time,
    limited health data (in text form) from the departments' existing
    health information systems.

    [20] AHLTA was formerly known as CHCS II.

    [21] The name CHDR, pronounced "cheddar," combines the names of the two
    repositories.

    [22] The contract for this study is still ongoing.

    [23] GAO, Computer-Based Patient Records: VA and DOD Efforts to
    Exchange Health Data Could Benefit from Improved Planning and Project
    Management, [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-04-687]
    (Washington, D.C.: June 7, 2004).

    [24] DOD has populated CDR with information for outpatient encounters,
    drug allergies, and order entries and results for outpatient pharmacy
    and lab orders. VA has populated HDR with patient demographics, vital
    signs records, allergy data, and outpatient pharmacy data; in July
    2007, the department added chemistry and hematology, and in September
    2007, added microbiology.

    [25] Standardizing the data involves different tasks for each
    department. That is, although VA's health records are already
    electronic, it must still convert them into the standardized format
    appropriate for its repository. DOD must convert and standardize
    current records from its multiple systems, but it must also address
    health records that are not automated.

    [26] That is, they are matched on certain identifiers--first name, last
    name, date of birth, Social Security number--in both agencies' health
    information systems and established as "active" shared patients.

    [27] December 2004 DOD and VA Joint Strategic Plan.

    [28] Those eligible are active-duty service members, National Guard and
    Reserve members, retirees, their families, survivors and certain former
    spouses.

    [29] According to DOD officials, about 7.29 million individuals are
    enrolled in TRICARE. These people can seek care in both the direct care
    system (military medical facilities) and the purchased care system
    (nonmilitary medical facilities).

    [30] These data standards are known as RxNorm and Unified Medical
    Language System (UMLS) for medications and drug allergies.

    [31] Beta testing is testing of a prerelease version of software by
    selected cooperating users.

    [32] These sites are the Naval Medical Center in Portsmouth, Va.;
    Eisenhower Army Medical Center in Fort Gordon, Ga.; and Goodfellow Air
    Force Base in San Angelo, Tex.

    [33] Before these appointments, both the officials had been involved in
    the planning and implementation of the departments' current sharing
    capabilities.

    [34] These data were defined in response to the recommendation by the
    President's Commission on Care for America's Returning Wounded
    Warriors.

    [End of section]

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