United States General Accounting Office

GAO Report to the Chairman, Subcommittee

on Oversight and Investigations,
Committee on Veterans’ Affairs, House of
Representatives

June 2004
COMPUTER-BASED
PATIENT RECORDS
VA and DOD Efforts to
Exchange Health Data
Could Benefit from
Improved Planning
and Project
Management

GAO-04-687
a
 June 2004

COMPUTER-BASED PATIENT RECORDS

VA and DOD Efforts to Exchange Health

Highlights of GAO-04-687, a report to the Data Could Benefit from Improved
Subcommittee on Oversight and
Investigations, House Committee on Planning and Project Management
Veterans' Affairs

A critical element of the While VA and DOD continue to move forward in agreeing to and adopting
Department of Veterans Affairs’ standards for clinical data, they have made little progress since last winter
(VA) information technology toward defining how they intend to achieve an electronic medical record
program is its continuing work based on the two-way exchange of patient health data. The departments
with the Department of Defense
continue to face significant challenges in achieving this capability.
(DOD) to achieve the ability to
exchange patient health care
information and create electronic • VA and DOD lack an explicit architecture—a blueprint—that provides
medical records for use by details on what specific technologies will be used to achieve the
veterans, active-duty military electronic medical record by the end of 2005.
personnel, and their health care
providers. • The departments have not fully implemented a project management
structure that establishes lead decision-making authority and ensures the
This report provides an assessment necessary day-to-day guidance of and accountability for their investment
of the departments’ recent progress in and implementation of this project.
toward achieving an electronic
two-way exchange of health care • They are operating without a project management plan describing the
data, along with recommendations specific responsibilities of each department in developing, testing, and
based on GAO’s work. deploying the electronic interface.

In seeking to provide a two-way exchange of health information between

To help ensure progress by the their separate health information systems, VA and DOD have chosen a
departments in achieving the two- complex and challenging approach—one that necessitates the highest levels
way exchange of health of project discipline. Yet critical project components are currently lacking.
information, GAO recommends As such, the departments risk investing in a capability that could fall short of
that the Secretaries of Veterans what is expected and what is needed. Until a clear approach and sound
Affairs and Defense develop an planning are made integral parts of this initiative, concerns about exactly
architecture for the systems’
what capabilities VA and DOD will achieve—and when—will remain.
electronic interface, establish a
project management structure that
designates a lead decision-making
entity, and create and implement a
coordinated project plan for
developing the interface between
the departments’ health
information systems. In
commenting on a draft of this
report, the departments agreed
with our recommendations and
identified actions planned or
undertaken to address them.

www.gao.gov/cgi-bin/getrpt?GAO-04-687.

To view the full product, including the scope

and methodology, click on the link above.
For more information, contact Linda D.
Koontz at (202) 512-6240 or
koontzl@gao.gov.
Contents

Letter 1
Results in Brief 2
Background 3
The Two-Way Exchange Could Benefit from Improved Planning
and Project Management 6
Conclusions 9
Recommendations for Executive Action 10
Agency Comments 11

Appendix I Comments from the Secretary of Veterans Affairs 12

Appendix II Comments from the Director, Interagency Program

Integration & External Liaison for Health Affairs 15

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Page i GAO-04-687 VA/DOD Health Data Exchange

United States General Accounting Office
Washington, DC 20548

June 7, 2004

The Honorable Steve Buyer

Chairman, Subcommittee on Oversight
and Investigations
Committee on Veterans’ Affairs
House of Representatives

Dear Mr. Chairman:

As you know, the Departments of Veterans Affairs (VA) and Defense

(DOD) are currently pursuing the ability to exchange patient health care
data and create an electronic medical record for veterans and active-duty
military personnel. While in military status and later as veterans, many
patients tend to be highly mobile and may have health records residing at
multiple medical facilities within and outside of the United States. Having
readily accessible medical data on these individuals is important to
providing high-quality health care to them and to adjudicating any
disability claims that they may have. This goal of having electronic medical
records that display all available clinical information in each department’s
health information system is a positive and necessary step. However, as
we have previously reported,1 the lack of progress the departments have
made in accomplishing this two-way exchange of health care data raises
doubts as to when and to what extent a true electronic medical record will
be achieved.

As requested, our objective was to assess VA’s and DOD’s recent progress
toward achieving an electronic two-way exchange of health care data. In
conducting our work, we analyzed key documentation supporting VA’s
and DOD’s strategy for developing and implementing the two-way
electronic exchange of health data. In addition, we reviewed
documentation to identify the costs incurred by VA and DOD in developing
technology to support the sharing of health data, including costs for the

1
U.S. General Accounting Office, Computer-Based Patient Records: Sound Planning and
Project Management Are Needed to Achieve a Two-Way Exchange of VA and DOD Health
Data, GAO-04-402T (Washington, D.C.: March 17, 2004) and Computer-Based Patient
Records: Short-Term Progress Made, but Much Work Remains to Achieve a Two-Way
Data Exchange Between VA and DOD Health Systems, GAO-04-271T (Washington, D.C.:
November 19, 2003).

Page 1 GAO-04-687 VA/DOD Health Data Exchange

 Government Computer-Based Patient Record/Federal Health Information
Exchange (GCPR/FHIE) initiatives, DOD’s Composite Health Care System
II, and VA’s HealtheVet VistA. We did not audit the reported costs, and
thus, cannot attest to their accuracy or completeness. We supplemented
our analyses with interviews of VA and DOD officials responsible for key
decisions and actions on the initiatives. Our work was performed at VA
and DOD offices located in the Washington, D.C., area in accordance with
generally accepted government auditing standards, from December 2003
to May of this year.

While VA and DOD have continued to define data standards that are
Results in Brief essential to facilitating the exchange of data, they have made little
progress toward defining just how they intend to achieve the two-way
exchange of patient health data between their two health information
systems currently under development. Although VA officials recognize the
importance of having an architecture that describes in detail how they
plan to develop an electronic interface between those systems, they
acknowledge that the departments’ efforts continue to be guided by a less
specific, high-level strategy that has been in place since September 2002.
Compounding the challenge and uncertainties of developing the electronic
interface is that VA and DOD have not fully established a project
management structure to ensure the necessary day-to-day guidance of and
accountability for the departments’ investment in and implementation of
this capability. Although maintaining that they were collaborating on this
initiative through a joint working group and receiving oversight from
executive-level councils, neither department has the authority to make
final project decisions binding on the other. Further, the departments are
operating without a project management plan describing the specific
responsibilities of VA and DOD in developing, testing, and deploying the
interface. In the absence of an explicit architecture and critical project
management, VA and DOD are progressing slowly in their development of
the interface and their limited progress to date calls into question the
departments’ ability to begin exchanging patient health information by
their targeted date of the end of 2005.

Given the implications that readily accessible medical data can have for
improving the quality of health care and disability claims processing for
military members and veterans, we are recommending that the Secretaries
of Veterans Affairs and Defense take a number of actions to improve the
likelihood of successfully achieving the two-way exchange of medical
data.

Page 2 GAO-04-687 VA/DOD Health Data Exchange

 In commenting on a draft of this report, the Secretary of Veterans Affairs
and DOD’s Interagency Program Integration and External Liaison for
Health Affairs agreed with the report’s recommendations. In their
comments, they provided information on actions planned or undertaken to
improve program management.

Since 1998 VA and DOD have been trying to achieve the capability to share
Background patient health care data electronically. The original effort—the
government computer-based patient record (GCPR) project—included the
Indian Health Service (IHS) and was envisioned as an electronic interface
that would allow physicians and other authorized users at VA, DOD, and
IHS health facilities to access data from any of the other agencies’ health
information systems. The interface was expected to compile requested
patient information in a virtual record that could be displayed on a user’s
computer screen.

Our prior reviews of the GCPR project determined that the lack of a lead
entity, clear mission, and detailed planning to achieve that mission made it
difficult to monitor progress, identify project risks, and develop
appropriate contingency plans. Accordingly, reporting on this project2 in
April 2001 and again in June 2002, we made several recommendations to
help strengthen the management and oversight of GCPR. Specifically, in
2001 we recommended that the participating agencies (1) designate a lead
entity with final decision-making authority and establish a clear line of
authority for the GCPR project, and (2) create comprehensive and
coordinated plans that included an agreed-upon mission and clear goals,
objectives, and performance measures, to ensure that the agencies could
share comprehensive, meaningful, accurate, and secure patient health care
data. In 2002, we recommended that the participating agencies revise the
original goals and objectives of the project to align with their current
strategy, commit the executive support necessary to adequately manage
the project, and ensure that it followed sound project management
principles. VA and DOD took specific measures in response to our
recommendations for enhancing overall management and accountability
of the project.

2
U.S. General Accounting Office, Veterans Affairs: Sustained Management Attention Is
Key to Achieving Information Technology Results, GAO-02-703 (Washington, D.C.: June
12, 2002) and Computer-Based Patient Records: Better Planning and Oversight By VA,
DOD, and IHS Would Enhance Health Data Sharing, GAO-01-459 (Washington, D.C.: April
30, 2001).

Page 3 GAO-04-687 VA/DOD Health Data Exchange

By July 2002, VA and DOD had revised their strategy and had made some
progress toward electronically sharing patient health data. The two
departments had renamed the project the Federal Health Information
Exchange (FHIE) program and, consistent with our prior
recommendation, had finalized a memorandum of agreement designating
VA as the lead entity for implementing the program. This agreement also
established FHIE as a joint effort that would allow the exchange of health
care information in two phases. The first phase, completed in mid-July
2002, enabled the one-way transfer of data from DOD’s existing health
information system to a separate database that VA clinicians could access.
A second phase, finalized this past March, completed VA’s and DOD’s
efforts to add to the base of patient health information available to VA
clinicians via this one-way sharing capability. The departments reported
total GCPR/FHIE costs of about $85 million through fiscal year 2003.

The revised strategy also envisioned the pursuit of a longer term, two-way
exchange of health information between DOD and VA.3 Known as
HealthePeople (Federal), this initiative is premised upon the departments’
development of a common health information architecture comprising
standardized data, communications, security, and high-performance health
information systems. The joint effort is expected to result in the secured
sharing of health data required by VA’s and DOD’s health care providers
between systems that each department is currently developing—DOD’s
Composite Health Care System (CHCS) II and VA’s HealtheVet VistA.

DOD began developing CHCS II in 1997 and has completed the

development of its associated clinical data repository—a key component
for the planned electronic interface. The department expects to complete
deployment of all of its major system capabilities by September 2008.4 It
reported expenditures of about $464 million for the system through fiscal
year 2003. VA began work on HealtheVet VistA and its associated health
data repository in 2001, and expects to complete all six initiatives

3
IHS, was not included in FHIE, but was expected to assume a role in the longer-term
project------HealthePeople (Federal).
4
DOD’s CHCS II capabilities are being deployed in blocks. Block 1 provides a graphical user
interface for clinical outpatient processes; block 2 supports general dentistry; block 3
provides pharmacy, laboratory, radiology, and immunizations capabilities; block 4 provides
inpatient and scheduling capabilities; and block 5 will provide additional capabilities as
defined.

Page 4 GAO-04-687 VA/DOD Health Data Exchange

comprising this system in 2012.5 VA reported spending about $120 million
on HealtheVet VistA through fiscal year 2003.

Under the HealthePeople (Federal) initiative, VA and DOD envision that,

upon entering military service, a health record for the service member will
be created and stored in DOD’s CHCS II clinical data repository. The
record will be updated as the service member receives medical care. When
the individual separates from active duty and, if eligible, seeks medical
care at a VA facility, VA will then create a medical record for the
individual, which will be stored in its health data repository. Upon viewing
the medical record, the VA clinician would be alerted and provided access
to the individual’s clinical information residing in DOD’s repository. In the
same manner, when a veteran seeks medical care at a military treatment
facility, the attending DOD clinician would be alerted and provided with
access to the health information in VA’s repository. According to the
departments, this planned approach would make virtual medical records
displaying all available patient health information from the two
repositories accessible to both departments’ clinicians. VA officials have
stated that they anticipate being able to exchange some degree of health
information through an interface of their health data repository with
DOD’s clinical data repository by the end of calendar year 2005.

5
The six initiatives that make up HealtheVet VistA are health data repository, billing
replacement, laboratory, pharmacy, imaging, and appointment scheduling replacement.

Page 5 GAO-04-687 VA/DOD Health Data Exchange

 While VA and DOD are making progress in agreeing to and adopting
The Two-Way standards for clinical data,6 they continue to face significant challenges in
Exchange Could providing a virtual medical record based on the two-way exchange of data
as part of their HealthePeople (Federal) initiative. Specifically, VA and
Benefit from DOD do not have
Improved Planning
• an explicit architecture that provides details on what specific technologies
and Project they will use to achieve the exchange capability;
Management
• a fully established project management structure that will ensure the
necessary day-to-day guidance of and accountability for the departments’
investment in and implementation of the exchange; and

• a project management plan describing the specific responsibilities of each

department in developing, testing, and deploying the interface and
addressing security requirements.

System Architecture Not VA’s and DOD’s ability to exchange data between their separate health
Developed information systems is crucial to achieving the goals of HealthePeople
(Federal). Yet, successfully sharing health data between the departments
via a secure electronic interface between each of their data repositories
can be complex and challenging, and depends significantly on the
departments’ having a clearly articulated architecture, or blueprint,
defining how specific technologies will be used to achieve the interface.
Developing, maintaining, and using an architecture is a best practice in
engineering information systems and other technological solutions. An
architecture would articulate, for example, the system requirements and
design specifications, database descriptions, and software descriptions
that define the manner in which the departments will electronically store,
update, and transmit their data.

VA and DOD lack an explicit architecture that provides details on what

specific technologies they will use to achieve the exchange capability, or

6
Standardized clinical data is important for exchanging health information between
disparate systems. The Institute of Medicine’s Committee on Data Standards for Patient
Safety has reported the lack of common data standards as a key factor preventing
information sharing within the health care industry. VA and DOD, along with the
Department of Health and Human Services, have been active participants in the
Consolidated Health Informatics initiative. As part of this initiative, the Secretary of Health
and Human Services announced in early May the adoption of 15 new standards to enable
the exchange of health information.

Page 6 GAO-04-687 VA/DOD Health Data Exchange

just what they will be able to exchange by the end of 2005—their projected
date for having this capability operational. While VA officials stated that
they recognize the importance of a clearly defined architecture, they
acknowledged that the departments’ actions were continuing to be driven
by the less specific, high-level strategy that has been in place since
September 2002.

Officials in both departments stated that a planned pharmacy prototype

initiative, begun this past March in response to requirements of the
National Defense Authorization Act of 2003,7 would assist them in defining
the electronic interface technology needed to exchange patient health
information. The act mandated that VA and DOD develop a real-time
interface, data exchange, and capability to check prescription drug data
for outpatients by October 1, 2004. In late February, VA hired a contractor
to develop the planned prototype but the departments had not yet fully
determined the approach or requirements for it. DOD officials stated that
the contractor was expected to more fully define the technical
requirements for the prototype. In late April, the departments reported
approval of the contractor’s requirements and technical design for the
prototype.

While the pharmacy prototype may help define a technical solution for the
two-way exchange of health information between the two departments’
existing systems, there is no assurance that this same solution can be used
to interface the new systems under development. Because the
departments’ new health information systems—major components of
HealthePeople (Federal)—are scheduled for completion over the next 4 to
9 years, the prototype may only test the ability to exchange data in VA’s
and DOD’s existing health systems. Thus, given the uncertainties regarding
what capabilities the pharmacy prototype will demonstrate, it is difficult to
predict how or whether the prototype initiative will contribute to defining
the architecture and technological solution for the two-way exchange of
patient health information for the HealthePeople (Federal) initiative.

7
Sec. 724 of the act mandates that the Secretaries of Veterans Affairs and Defense seek to
ensure that, on or before October 1, 2004, the two departments’ pharmacy data systems are
interoperable for VA and DOD beneficiaries by achieving real-time interface, data
exchange, and checking of prescription drug data of outpatients, and using national
standards for the exchange of outpatient medication information. The act further states
that if the specified interoperability is not achieved by that date, the Secretary of Veterans
Affairs shall adopt DOD’s Pharmacy Data Transaction System for VA’s use.

Page 7 GAO-04-687 VA/DOD Health Data Exchange

Fully Established Project Industry best practices and information technology project management
Management Structure Not principles stress the importance of accountability and sound planning for
in Place any project, particularly an interagency effort of the magnitude and
complexity of HealthePeople (Federal). Based on our past work, we have
found that a project management structure should establish relationships
between managing entities with each entity’s roles and responsibilities
clearly articulated.8 Further, it is important to establish final decision-
making authority with one entity.

However, VA and DOD have not fully established a project management

structure that will ensure the necessary day-to-day guidance of and
accountability for the departments’ investment in and implementation of
the two-way capability. According to officials in both departments a joint
working group and oversight by the Joint Executive Council and VA/DOD
Health Executive Council has provided the collaboration necessary for
HealthePeople (Federal).9 However, this oversight by the executive
councils is at a very high level, occurs either bimonthly or quarterly, and
encompasses all of the joint coordination and sharing efforts for health
services and resources. Since a lead entity has not been designated,
neither department has had the authority to make final project decisions
binding on the other. Further, the roles and responsibilities for each
department have not been clearly articulated. Without a clearly defined
project management structure, accountability and a means to monitor
progress are difficult to establish.

In early March, VA officials stated that the departments had designated a

program manager for the planned pharmacy prototype and were
establishing roles and responsibilities for managing the joint initiative to
develop an electronic interface. Just this month, officials from both
departments told us that this individual would be the program manager for
the electronic interface. However, they had not yet designated a lead entity

8
GAO-01-459.
9
The Joint Executive Council is comprised of the Deputy Secretary of Veterans Affairs, the
Under Secretary of Defense for Personnel and Readiness, and the cochairs of joint councils
on health, benefits, and capital planning. The council meets on a quarterly basis to
recommend strategic direction of joint coordination and sharing efforts. The VA/DOD
Health Executive Council is comprised of senior leaders from VA and DOD, who work to
institutionalize sharing and collaboration of health services and resources. The council is
cochaired by the VA Under Secretary for Health and DOD Assistant Secretary of Defense
for Health Affairs, and meets on a bimonthly basis.

Page 8 GAO-04-687 VA/DOD Health Data Exchange

 or provided documentation for the project management structure or their
roles and responsibilities for the HealthePeople (Federal) initiative.

Project Management Plan An equally important component necessary for guiding the development of
Lacking the electronic interface is a project management plan. Information
technology project management principles and industry best practices10
emphasize that a project management plan is needed to define the
technical and managerial processes necessary to satisfy project
requirements. Specifically, the plan should include, among other things,
the authority and responsibility of each organizational unit; a work
breakdown structure for all of the tasks to be performed in developing,
testing, and deploying the software, along with schedules associated with
the tasks; and a security policy.

However, the departments are currently operating without a project

management plan for HealthePeople (Federal) that describes the specific
responsibilities of each department in developing, testing, and deploying
the interface and addressing security requirements. This month, officials
from both departments stated that a pharmacy prototype project
management plan that includes a work breakdown structure and schedule
was developed in mid-March. They further stated that a work group that
reports to the integrated project team has been given responsibility for the
development of security and information assurance provisions. While
these actions should prove useful in guiding the development of the
prototype, they do not address the larger issue of how the departments
will develop and implement an interface to exchange health care
information between their systems by 2005.

Without a project management plan, VA and DOD lack assurance that they
can successfully develop and implement an electronic interface and the
associated capability for exchanging health information within the time
frames that they have established. VA and DOD officials stated that they
have begun discussions to establish an overall project plan.

Achieving an electronic interface that will enable VA and DOD to

Conclusions exchange patient medical records is an important goal, with substantial

10
Institute of Electrical and Electronics Engineers, IEEE/EIA Guide for Information
Technology (IEEE/EIA 12207.1 - 1997), April 1998.

Page 9 GAO-04-687 VA/DOD Health Data Exchange

 implications for improving the quality of health care and disability claims
processing for the nation’s military members and veterans. In seeking a
virtual medical record based on the two-way exchange of data between
their separate health information systems, VA and DOD have chosen a
complex and challenging approach that necessitates the highest levels of
project discipline, including a well-defined architecture for describing the
interface for a common health information exchange; an established
project management structure to guide the investment in and
implementation of this electronic capability; and a project management
plan that defines the technical and managerial processes necessary to
satisfy project requirements. These critical components are currently
lacking; thus, the departments risk investing in a capability that could fall
short of expectations. The continued absence of these components
elevates concerns about exactly what capabilities VA and DOD will
achieve—and when.

To encourage significant progress on achieving the two-way exchange of

Recommendations for health information, we recommend that the Secretaries of Veterans Affairs
Executive Action and Defense instruct the Acting Chief Information Officer for Health and
the Chief Information Officer for the Military Health System, respectively,
to

• develop an architecture for the electronic interface between their health

systems that includes system requirements, design specifications, and
software descriptions;

• select a lead entity with final decision-making authority for the initiative;

• establish a project management structure to provide day-to-day guidance

of and accountability for their investments in and implementation of the
interface capability; and

• create and implement a comprehensive and coordinated project

management plan for the electronic interface that defines the technical
and managerial processes necessary to satisfy project requirements and
includes (1) the authority and responsibility of each organizational unit;
(2) a work breakdown structure for all of the tasks to be performed in
developing, testing, and implementing the software, along with schedules
associated with the tasks; and (3) a security policy.

Page 10 GAO-04-687 VA/DOD Health Data Exchange

 The Secretary of Veterans Affairs provided written comments on a draft of
Agency Comments this report and we received comments via e-mail from DOD’s Interagency
Program Integration and External Liaison for Health Affairs; both
concurred with the recommendations. Each department’s comments are
reprinted in their entirety as appendixes I and II, respectively. In their
comments, the officials also provided information on actions taken or
underway that, in their view, address our recommendations.

We are sending copies of this report to the Secretaries of Veterans Affairs

and Defense and to the Director, Office of Management and Budget.
Copies will also be available at no charge on GAO’s Web site at
www.gao.gov.

Should you have any question on matters contained in this report, please
contact me at (202) 512-6240, or Barbara Oliver, Assistant Director, at
(202) 512-9396. We can also be reached by e-mail at koontzl@gao.gov and
oliverb@gao.gov, respectively. Other key contributors to this report were
Michael P. Fruitman, Valerie C. Melvin, J. Michael Resser, and Eric L.
Trout.

Sincerely yours,

Linda D. Koontz
Director, Information Management Issues

Page 11 GAO-04-687 VA/DOD Health Data Exchange

 Appendix I: Comments from the Secretary of
Appendix I: Comments from the Secretary of
Veterans Affairs

Veterans Affairs

Page 12 GAO-04-687 VA/DOD Health Data Exchange

Appendix I: Comments from the Secretary of
Veterans Affairs

Page 13 GAO-04-687 VA/DOD Health Data Exchange

Appendix I: Comments from the Secretary of
Veterans Affairs

Page 14 GAO-04-687 VA/DOD Health Data Exchange

 Appendix II: Comments from the Director,
Appendix II: Comments from the Director,
Interagency Program Integration & External
Liaison for Health Affairs

Interagency Program Integration & External

Liaison for Health Affairs

(310710)
Page 15 GAO-04-687 VA/DOD Health Data Exchange
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