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 
departmentsï¿½ 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 interoperabilityï¿½that 
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 onlyï¿½a 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 
departmentsï¿½ 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 GAOï¿½s 
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 
[email protected]. 

[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 [email protected]. 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 
[email protected], and Mr. Gunther Zimmerman, who may be reached 
at, (703) 681-4360, or [email protected]. 

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 [email protected]: 

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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