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Transition of Care for OEF and OIF Servicemembers and Veterans' which 
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June 30, 2006: 

The Honorable Michael Bilirakis:
Chairman:
Subcommittee on Oversight and Investigations: Committee on Veterans' 
Affairs:
House of Representatives: 

Subject: VA and DOD Health Care: Efforts to Provide Seamless Transition 
of Care for OEF and OIF Servicemembers and Veterans: 

Dear Mr. Chairman: 

As of the end of March 2006, over 1.3 million[Footnote 1] U.S. military 
servicemembers had served or were serving in Operation Enduring Freedom 
(OEF) or Operation Iraqi Freedom (OIF).[Footnote 2] These 
servicemembers, including members of the reserves and National Guard, 
may be eligible to receive health care from the Department of Veterans 
Affairs (VA) while serving on active duty or upon separating from 
active duty. Although the Department of Defense (DOD) provides health 
care services to servicemembers under TRICARE,[Footnote 3] legislation 
passed by the Congress in May 1982 authorized VA to provide health care 
services to servicemembers in time of war or national emergency, when 
DOD may have insufficient resources to care for casualties.[Footnote 4] 
Through December 16, 2005, DOD had arranged for 193 active duty 
servicemembers with serious injuries--traumatic brain injuries and 
other complex trauma, such as missing limbs--to receive medical and 
rehabilitative[Footnote 5] care at VA polytrauma rehabilitation centers 
(PRC).[Footnote 6] In addition, about 30 percent (over 144,000) of the 
servicemembers who had separated from active duty following service in 
OEF or OIF have sought VA health care, including over 4,000 who 
received inpatient care at VA medical facilities. 

In September 2005, we testified on VA's collaboration with DOD to 
provide seamless transition of care for servicemembers between DOD and 
VA health care systems--that is, no interruption of care as the person 
moves from being a DOD patient to being a VA patient.[Footnote 7] We 
reported that VA has developed policies and procedures that direct its 
medical facilities to provide OEF and OIF servicemembers with timely 
access to care but that the sharing of health information between DOD 
and VA was limited. You asked us to update the information we provided 
in our testimony by reviewing the efforts VA is making to inform 
servicemembers and veterans about VA health care services and to help 
ensure that there is a seamless transition of care for servicemembers 
from DOD's to VA's health care system. We addressed the following 
questions: 

1. What outreach efforts has VA made to inform OEF and OIF 
servicemembers and veterans about the VA health care services that may 
be available to them? 

2. What actions has VA taken to facilitate the seamless transition of 
medical and rehabilitation care for seriously injured OEF and OIF 
servicemembers who are transferred between DOD medical treatment 
facilities (MTF) and PRCs? 

3. What special educational activities or clinical tools is VA using to 
help ensure its medical providers are aware of and recognize the needs 
of eligible OEF and OIF servicemembers and veterans? 

To determine outreach efforts VA has made to inform OEF and OIF 
servicemembers and veterans about the VA health care services that may 
be available to them, we interviewed, and collected supporting 
documentation from, VA officials on their efforts and programs that 
have been established to inform servicemembers and veterans about VA 
health care services. We also observed briefings given by VA 
representatives at two military installations[Footnote 8] to active 
duty and reserve servicemembers about VA health care services for which 
they may be eligible. 

To identify actions VA has taken to facilitate the seamless transition 
of care between MTFs and PRCs for servicemembers seriously injured in 
OEF and OIF, we reviewed VA directives, policies, and handbooks 
governing access to VA health care by OEF and OIF servicemembers and 
veterans. We also visited the two MTFs that treat most of the seriously 
injured OEF and OIF servicemembers--Walter Reed Army Medical Center and 
the National Naval Medical Center, both located in the Washington, 
D.C., area--and the four PRCs that treat them. The PRCs are located at 
VA Medical Centers in Palo Alto, California; Tampa, Florida; 
Minneapolis, Minnesota; and Richmond, Virginia. During those visits, we 
interviewed medical providers and reviewed the VA electronic medical 
records of the 193 seriously injured servicemembers who were admitted 
to the PRCs from January 7, 2002,[Footnote 9] through December 16, 
2005. In addition, we attended a discharge planning conference for an 
OIF servicemember being discharged from a PRC to document the 
information provided to the servicemember about his follow-up health 
care from VA and DOD. We made subsequent visits to the Richmond and 
Tampa PRCs to observe the capability of PRC providers to access DOD 
electronic medical records. 

To identify the special educational activities or clinical tools that 
VA is using to help ensure its medical providers are aware of and 
recognize the needs of eligible OEF and OIF servicemembers and 
veterans, we interviewed, and collected supporting documentation from, 
VA officials. While we were at the Naval Station Norfolk conducting 
audit work, we also visited the VA Medical Center in Hampton, Virginia, 
to obtain information on the educational activities and clinical tools 
VA uses when treating OEF and OIF servicemembers and veterans. We also 
obtained this information from the four PRCs. Further, we determined 
the number of VA medical providers and other staff who completed online 
educational courses developed by VA. 

Our review was conducted from May 2005 through June 2006 in accordance 
with generally accepted government auditing standards. 

Results in Brief: 

VA has made a variety of outreach efforts to provide OEF and OIF 
servicemembers and veterans and their families with information on VA 
health care services. VA reported that from October 1, 2000, through 
May 31, 2006, it provided about 36,000 briefings to almost 1.4 million 
active duty, reserve, and National Guard servicemembers about VA health 
care services that may be available to them. In some cases, family 
members also attended these briefings, which were provided at over 200 
sites, including 70 sites outside the United States. VA also maintains 
a Web site containing health information focused on OEF and OIF 
servicemembers and veterans, distributes brochures and pamphlets to 
provide information about topics of interest to OEF and OIF 
servicemembers and veterans and their families, and sends letters and 
newsletters to veterans about VA health care services and health issues 
specific to veterans. 

VA has taken several actions to facilitate the transition of medical 
and rehabilitative care for seriously injured servicemembers who are 
being transferred from MTFs to PRCs. In April 2003, the Secretary of VA 
authorized VA medical facilities to give priority to OEF and OIF 
servicemembers over veterans, except those with service-connected 
disabilities. In April 2004, VA signed a memorandum of agreement (MOA) 
with DOD that established the referral procedures for transferring 
injured servicemembers from DOD to VA medical facilities. VA and DOD 
also established joint programs to ease the transfer of injured 
servicemembers to VA medical facilities, including a program that 
assigned VA social workers to selected MTFs to coordinate patient 
transfers to VA medical facilities. Nevertheless, problems remain in 
the process for electronically sharing the medical records VA needs to 
determine whether servicemembers are medically stable enough to 
participate in vigorous rehabilitation activities. According to VA 
officials, the transfer could be more efficient if PRC medical 
personnel had real-time access to the servicemembers' complete DOD 
electronic medical records from the referring MTFs. VA and DOD reported 
that as of December 2005 only two of the PRCs had requested and been 
granted real-time access to the electronic medical records maintained 
at Walter Reed Army Medical Center. One of these PRCs had also been 
granted access to the electronic medical records at the National Naval 
Medical Center. However, problems continue to exist with the PRCs' 
ability to access DOD electronic medical records. During a visit to the 
two PRCs in April 2006, we found that neither facility could access the 
DOD electronic medical records at Walter Reed Army Medical Center 
because of technical difficulties. Furthermore, while VA's electronic 
medical record system captures a wide range of patient information, we 
found that at the time we conducted our audit work it did not always 
contain a complete record of information related to the patient's 
discharge from the PRC, such as dates and times of follow-up medical 
appointments--information that could be useful for maintaining 
continuity of care or responding to a patient inquiry about future 
appointments. In response to our concerns about this problem, VA has 
taken corrective action. The department has developed a template that 
identifies the information given to servicemembers at discharge from 
PRCs. The template has been included in VA's electronic medical record 
for use systemwide. 

VA has developed a number of educational activities and online clinical 
tools to help ensure that VA medical providers and other staff are 
aware of and recognize the health care needs of OEF and OIF 
servicemembers and veterans. Examples of VA's educational efforts 
include developing online courses on infectious diseases of Southwest 
Asia; holding conferences on brain injuries; conducting conference 
calls, each of which provided more than 100 VA staff with information 
on transferring servicemembers from DOD to VA health care services; and 
developing publications on the long-term effects of using an 
antimalarial drug. VA has also provided educational activities at two 
East Coast centers targeting medical professionals (such as physicians, 
nurses, and social workers), including conferences on topics such as 
physical and mental health issues, infectious disease issues, and 
health care services provided by VA. Furthermore, VA has developed 
clinical tools to help its staff be aware of and responsive to the 
needs of OEF and OIF servicemembers and veterans. For example, it has 
added reminder screens to its electronic medical records that pop up 
when staff are accessing patients' records and prompt them to ask 
questions about OEF-and OIF-related medical and psychological 
conditions, such as infectious diseases and depression. VA and DOD have 
also developed guidelines to assist clinicians in providing medical 
care to OEF and OIF veterans. 

We provided a draft of this report to VA and DOD for comment. VA 
concurred with the information presented in our draft report. DOD 
commented that the report portrays the numerous efforts that have been 
made to improve the efficacy of programs designed to ensure a smooth 
transition and continuity of care as servicemembers transition back and 
forth between DOD and VA health care systems. DOD also stated that the 
report contained several inaccuracies; however, we maintain that the 
information contained in the report accurately presents the results of 
our audit work. 

Background: 

DOD has reported that as of June 26, 2006, over 19,000 servicemembers 
have been wounded in action since the onset of OEF and OIF. Some of 
these servicemembers are surviving injuries that would have been fatal 
in past conflicts. In World War II, about 30 percent of American 
servicemembers wounded in combat died. Because of medical advances, 
this proportion has dropped to 3 percent for OEF and OIF 
servicemembers, but many of them are returning home with severe 
disabilities, including traumatic brain injuries and missing limbs. In 
2005, DOD reported that about 65 percent of the OEF and OIF 
servicemembers wounded in action were injured by blasts and fragments 
from improvised explosive devices, land mines, and other explosive 
devices. More recently, DOD estimated in 2006 that the percentage of 
those injured by blasts and fragments who have some degree of trauma to 
the brain ranged from less than 20 percent to 28 percent. These 
injuries may require comprehensive inpatient rehabilitation services to 
address complex cognitive, physical, and mental health 
impairments.[Footnote 10] 

While servicemembers are on active duty, DOD manages where they receive 
their care--at an MTF, a TRICARE civilian provider, or a VA medical 
facility.Once discharged from the military or demobilized from the 
reserves or National Guard, veterans may be eligible to receive care 
from VA's health care system. 

From the OEF and OIF conflict areas, seriously injured servicemembers 
are usually brought to Landstuhl Regional Medical Center in Germany for 
treatment. From there, they are usually transported to MTFs located in 
the United States, with most of the seriously injured admitted to 
Walter Reed Army Medical Center or the National Naval Medical Center. 
Once seriously injured servicemembers are medically stabilized, DOD can 
elect to send those with traumatic brain injuries and other complex 
trauma, such as missing limbs, to one of the four PRCs for 
rehabilitative services. 

The transfer of injured servicemembers from MTFs to VA medical 
facilities for medical care requires the exchange of health information 
between DOD and VA. In August 1998, the President issued a directive 
requiring VA and DOD to develop a computer-based patient record system 
that would accurately and efficiently exchange information between the 
departments. The directive stated that VA and DOD should define, 
acquire, and implement a fully integrated computer-based patient record 
available across the entire spectrum of health care delivery over the 
lifetime of the patient.[Footnote 11] 

Since receiving the President's directive, VA and DOD have been working 
to exchange patient health information electronically and ultimately to 
have interoperable electronic medical records. VA and DOD have begun to 
implement applications that exchange limited electronic medical 
information between the departments' existing health information 
systems. One of these applications--the Bidirectional Health 
Information Exchange--is a project to achieve the two-way exchange of 
health information on patients who receive care from both VA and DOD. 
The application has been implemented at all VA sites and at 14 DOD 
sites to exchange information such as pharmacy and allergy data, but as 
we testified in September 2005, the goal of systemwide two-way 
electronic exchange of patient records remains far from being 
realized.[Footnote 12] As a separate effort, VA and DOD have undertaken 
an initiative to allow the four PRCs to electronically access medical 
records at Walter Reed Army Medical Center and the National Naval 
Medical Center to obtain information on seriously injured OEF and OIF 
servicemembers. The capability for electronic access was requested by 
the Richmond and Tampa PRCs in 2005 and by the Palo Alto and 
Minneapolis PRCs in 2006. This capability will be limited to a small 
number of providers at each of the PRCs. 

Apart from joint efforts to share medical information, VA and DOD 
separately have developed electronic systems for recording and 
accessing patient health information. VA's electronic medical records 
are maintained in a system that captures a wide range of patient 
information, including doctors' progress notes, vital signs, laboratory 
results, medications dispensed, drug allergies, radiological images, 
and clinical reminders. VA's system also allows the patient's complete 
medical record to be accessed from any VA medical facility. While DOD's 
electronic medical record system also captures information such as 
doctors' progress notes, vital signs, medications dispensed, and 
laboratory results, it does not include radiological images, vision and 
hearing tests, or anesthesia notes. In addition, DOD does not have a 
systemwide approach to electronic medical record management since the 
information is maintained and stored at individual MTFs or, in some 
locations, in networks that service multiple MTFs within a small 
geographic area. Under DOD's approach, all medical information cannot 
be electronically accessed by providers throughout DOD's health care 
system. For example, providers at Walter Reed Army Medical Center and 
the National Naval Medical Center can access each other's electronic 
medical records but cannot access medical records from Landstuhl 
Regional Medical Center in Germany. 

VA's Outreach Includes Briefings, Web Sites, and Newsletters: 

VA has taken a number of actions to provide OEF and OIF servicemembers 
and their families with information about VA health care services, such 
as the cost of the services, how to register for VA health care, and 
where to obtain VA health care. VA reported that from October 1, 2000, 
through May 31, 2006, it held about 36,000 briefings for almost 1.4 
million active duty, reserve, and National Guard servicemembers. These 
briefings were held at over 200 sites, including 70 sites located 
outside the United States. VA reported that over 8,000 family members 
attended some of these briefings from October 1, 2005, through May 31, 
2006. In addition, under a May 2005 MOA between VA and the National 
Guard, VA has trained staff hired by the National Guard to provide VA 
health and benefit information to National Guard units in each state. 

For both servicemembers and veterans, VA has also created a Web 
site[Footnote 13] that provides information for those who served in OEF 
and OIF, such as information on VA health and medical services, 
dependents' benefits and services, and transition assistance from 
military to civilian life. The Web site contains information about VA 
benefits available to active duty military personnel, including a page 
that briefly describes these benefits. VA has also developed a variety 
of informational materials, including a wallet-sized card with relevant 
toll-free telephone numbers and Web site addresses, fact sheets and 
pamphlets summarizing VA benefits, and a monthly video magazine called 
The American Veteran. VA reported that almost 1.4 million of the wallet-
sized cards have been distributed during briefings. Fact sheets and 
pamphlets are sent to VA medical facilities for distribution to 
veterans and are also available on VA's Web site. The video magazine 
reports information about VA services on a VA Web site[Footnote 14] and 
on the Pentagon Channel, which is available online[Footnote 15] and on 
cable television. 

VA also has outreach efforts designed specifically for active duty, 
reserve, and National Guard OEF and OIF veterans. The Secretary of VA 
sends new veterans a letter thanking them for their service to the 
country and informing them about VA health care services and assistance 
in their transition to civilian life. As of May 15, 2006, the Secretary 
had sent letters to over 530,000 OEF and OIF servicemembers who had 
left active duty. These letters include information about the VA health 
care services available to veterans and a toll-free number for 
obtaining additional health care information. In addition, from 
December 2003 through March 2006 VA sent four newsletters to OEF and 
OIF veterans with information on health issues of interest to these 
veterans. 

VA Activities Facilitate the Transition of Care for Seriously Injured 
OEF and OIF Servicemembers Transferred to PRCs: 

VA has taken a number of actions to facilitate the transition of 
medical and rehabilitation care for servicemembers who have been 
seriously injured in OEF and OIF and are being transferred between DOD 
and VA medical facilities. These actions focus on establishing and 
expanding internal initiatives for providing care to this population as 
well as VA's efforts to electronically share medical records with DOD. 

In April 2003, when the President declared a national emergency with 
respect to the Iraq conflict, the Secretary of VA issued a memorandum 
authorizing VA medical facilities to give priority to servicemembers 
who sustained injuries in OEF and OIF over veterans and others eligible 
for VA health care, except those with service-connected disabilities. 
In October 2003, VA issued a directive requiring its medical facilities 
to designate a point of contact to receive and expedite transfers of 
servicemembers from DOD to VA medical facilities. In April 2004, VA 
signed an MOA with DOD to provide health care and rehabilitation 
services to servicemembers who sustain spinal cord injury, traumatic 
brain injury, or visual impairment. The MOA established the referral 
procedures for transferring active duty inpatient servicemembers from 
DOD to VA medical facilities.[Footnote 16] In June 2005, VA issued a 
directive expanding the scope of care it would provide to include 
psychological treatment for family members and intensive clinical and 
social work case management services[Footnote 17] at its four regional 
traumatic brain injury rehabilitation centers and renamed these 
facilities PRCs. 

VA has also established joint programs with DOD to ease the transfer of 
injured servicemembers to VA medical facilities. In August 2003, VA and 
DOD established a program that assigned VA social workers to selected 
MTFs[Footnote 18] to coordinate patient transfers between DOD and VA 
medical facilities. The social workers make appointments for care, 
ensure continuity of therapy and medications, and follow up with 
patients after discharge. By late February 2006, VA reported that the 
social workers had received requests for transfer of care for over 
6,000 patients, and over three-fourths of them had been transferred to 
VA facilities; the rest of the requests were pending.[Footnote 19] 
Under another program, a uniformed servicemember was stationed at each 
PRC beginning in March 2005 to assist servicemembers being admitted to 
the PRC. The uniformed servicemembers serve as liaisons among injured 
servicemembers and their families, the MTFs, the PRCs, and the 
servicemembers' units. For example, they assist with reimbursement for 
travel and lodging costs for immediate family members. 

In January 2005, VA established the Seamless Transition Office to 
enhance servicemembers' transition back to civilian life by improving 
coordination within the Veterans Benefits Administration and the 
Veterans Health Administration,[Footnote 20] as well as between DOD and 
VA. The goals of the Seamless Transition Office related to health care 
include improving communication, coordination, and collaboration within 
VA and with DOD concerning health care, educating VA staff about OEF 
and OIF veterans' health care, and other needs. The office has been 
active in areas such as coordinating efforts of the VA social workers 
assigned to MTFs to help servicemembers transfer their health care from 
MTFs to VA health care facilities and issuing a handbook on the policy 
and procedures for PRCs, including recommended staffing levels for the 
different types of medical providers caring for patients. 

There are also a number of routinely scheduled teleconferences and 
videoconferences within VA and between VA and the military medical 
facilities to coordinate medical care for injured servicemembers and to 
discuss and resolve medical issues. Topics include issues that are 
general in nature and would apply to a number of servicemembers or that 
are specific to individual servicemembers. For example, monthly, and as 
needed, VA's Seamless Transition Office and PRC staff hold 
teleconferences to discuss such issues as obtaining DOD medical records 
and how to provide follow-up medical care once the servicemember is 
discharged from the PRC. Further, on a bimonthly basis, PRCs hold 
teleconferences or videoconferences with Walter Reed Army Medical 
Center and the National Naval Medical Center to discuss issues arising 
during the transfer of injured servicemembers from their facilities to 
the PRCs, such as obtaining military medical records. Servicemembers 
and their families sometimes participate in the videoconference to meet 
PRC staff prior to transfer. Also on a monthly basis, VA and DOD hold 
videoconferences to discuss medical and logistical issues that arise 
with injured servicemembers. These videoconferences include DOD medical 
providers from Landstuhl Regional Medical Center in Germany and combat 
medical units located in Iraq. For example, during one videoconference, 
VA and DOD staff discussed the blood filters[Footnote 21] that were 
being surgically implanted in injured servicemembers in Iraq.[Footnote 
22] Medical providers in Baghdad asked if there was a different type of 
blood filter that they could use that would make removal easier at the 
stateside MTF or PRC. 

Despite coordination, we found that the departments are having problems 
exchanging health care information electronically between the four PRCs 
and the two MTFs--Walter Reed Army Medical Center and the National 
Naval Medical Center. While our current review focused on the 
electronic transfer of information among these six facilities, over 5 
years ago we recommended that VA and DOD create comprehensive and 
coordinated plans to ensure that the departments can share 
comprehensive, meaningful, accurate, and secure patient health 
data.[Footnote 23] Both VA and DOD concurred with this recommendation 
and are in the process of implementing it. From a systemwide 
perspective, we testified over 2 years ago and again last September on 
the need for VA and DOD to intensify their efforts to implement the 
capability to share health care information electronically. In those 
testimonies, we recognized the actions VA and DOD had taken to 
electronically exchange health information but also acknowledged that 
much work remains to attain this goal.[Footnote 24] 

During our visits to the PRCs from October through December 2005, we 
observed that none of the PRCs had real-time access to the injured 
servicemembers' DOD electronic medical records from the transferring 
MTFs. Instead, the MTF faxed copies of some of the medical information, 
such as the servicemember's medical history and physical and doctor's 
progress notes from these records, to the PRC. Because this information 
did not always provide enough data for the PRC provider to determine if 
the servicemember was medically stable enough to be admitted to the PRC 
and to engage in vigorous rehabilitation activities and because the PRC 
did not have access to the complete medical records (paper or 
electronic), VA developed a standardized list of the minimum types of 
health care information needed about each servicemember transferring 
from an MTF. However, after they reviewed this basic medical 
information PRC providers stated that they frequently needed additional 
information and had to ask the PRC social worker to obtain it from the 
VA social worker at the MTF. For example, if the PRC provider noticed 
that the servicemember was on a particular antibiotic therapy, the 
provider might request the results of the most recent blood and urine 
cultures to determine if the servicemember was medically stable enough 
to participate in strenuous rehabilitation activities. According to PRC 
officials, obtaining additional medical information in this way rather 
than electronically was very time consuming and often required multiple 
phone calls and faxes between the facilities. 

According to VA officials, the main barrier to PRC medical providers' 
getting real-time access to medical records was DOD's interpretation of 
the Health Insurance Portability and Accountability Act of 1996 
(HIPAA)[Footnote 25] and the HIPAA Privacy Rule.[Footnote 26] The HIPAA 
Privacy Rule permits VA and DOD to share servicemembers' health 
information under certain circumstances, such as for purposes of 
treatment or if the individual signs a proper authorization. However, 
DOD officials told us they initially were reluctant to provide this 
access to VA because they were concerned that VA would have access to 
health information of all servicemembers, not only the information of 
those being transferred to the PRC for treatment. 

Since we initiated our review, the four PRCs and Walter Reed Army 
Medical Center and the National Naval Medical Center have reached 
separate agreements on the records VA would be able to access and have 
begun to take action to share medical records.[Footnote 27] During our 
initial visits, two PRCs--Richmond and Tampa--were in the process of 
separately negotiating with Walter Reed Army Medical Center to obtain 
real-time access to injured servicemembers' electronic medical records. 
VA reported that as of December 27, 2005, PRC providers in Richmond and 
Tampa have real-time access to these records. The Tampa PRC also gained 
access to the National Naval Medical Center's electronic medical 
records on February 21, 2006. VA and DOD officials have not established 
a date when all PRCs would have real-time access to electronic records 
at Walter Reed Army Medical Center and the National Naval Medical 
Center. 

In April 2006, we revisited the Tampa and Richmond PRCs and found that 
problems continued with access to DOD electronic medical records. 
Providers at both PRCs that had been granted electronic access by DOD 
to obtain medical information stated that they could not always access 
the DOD electronic records. For example, during our visits neither 
facility could access the DOD electronic medical records at Walter Reed 
Army Medical Center because of a technical problem. Furthermore, while 
a nurse practitioner at the Tampa PRC was able to access the electronic 
medical records at the National Naval Medical Center, the admitting PRC 
provider for rehabilitative services could not. 

While VA's electronic medical records offer ready access to VA medical 
information for its medical providers, we found that during our site 
visits some information related to servicemembers' and veterans' 
discharge from PRCs was not always entered into the records. When 
servicemembers and veterans are discharged from PRCs, many still 
require follow-up medical care at VA, DOD, or private-sector 
facilities. The social worker at the PRC is responsible for arranging 
follow-up appointments prior to the patient's discharge from the PRC. 
Information on follow-up appointments and points of contact is provided 
to the servicemember or veteran during the discharge planning 
conference, along with a large amount of other medical information and 
discharge instructions. Our review of 193 servicemembers' VA electronic 
medical records showed that 126 patients required follow-up medical 
appointments after discharge from the PRC[Footnote 28]. An examination 
of the 126 records indicated that appointments were made for 122 of the 
patients, with the remaining 4 patients instructed to call their local 
VA medical centers for appointments. However, while the date and time 
for the appointment was in the electronic medical record, it was not 
clearly summarized in 96 of 122 of these records, nor was there 
evidence that it was given to the patient. In addition, 75 of the 122 
records did not clearly indicate the points of contact, nor was there 
evidence that this information was given to the patient. If this 
information were clearly documented in patients' electronic medical 
records, it would be available to VA providers who may need it to 
manage future care. 

In February 2006, in response to questions we raised during our review, 
VA developed a template for PRC social workers to complete when a 
patient is discharged. The social worker includes on the template 
information on follow-up medical appointments, contact names and 
telephone numbers for the medical facilities where the servicemember is 
going to obtain follow-up medical care, military contacts, and PRC 
contacts. This template is entered into the electronic medical record. 
During our visit to the Tampa and Richmond PRCs in April 2006, we found 
that the social workers had been using the templates for patients 
discharged since mid-March 2006. 

VA Is Using Courses, Conferences, and Online Clinical Tools to Help 
Ensure Medical Providers Are Aware of and Recognize Needs of Eligible 
OEF and OIF Servicemembers and Veterans: 

VA has developed activities to educate its medical providers and other 
staff on the health care needs of those who are or have been deployed 
in OEF and OIF. As part of its Veterans Health Initiatives, VA produced 
14 educational courses that address OEF-and OIF-related topics, such as 
traumatic brain injuries and infectious diseases of Southwest Asia. 
These courses are available on VA's intranet, over the Internet, and on 
compact discs. As of December 31, 2005, VA reported that nearly 2,000 
courses had been completed by VA staff, including nearly 1,200 courses 
that were completed by physicians. Also over 12,000 courses were 
completed by non-VA staff, such as veterans, family members, and staff 
from veterans service organizations. 

VA medical centers have also used conferences and in-house 
presentations to train staff on the needs of OEF and OIF servicemembers 
and veterans. For example, the Tampa PRC sponsored blast injury 
conferences in 2004 and 2005 that were attended by physicians, nurses, 
psychologists, and social workers. In addition, from April 2005 through 
April 2006, VA held five 1-hour conference calls for VA social workers 
that focused on the transfer of care for servicemembers from DOD to VA 
medical facilities, including information such as ways to be proactive 
in working with military families as they transition from active duty 
to veteran status and recognizing the signs and symptoms of stress and 
post-traumatic stress disorder in returning OEF and OIF veterans. VA 
reported that attendance for the conference calls ranged from 105 to 
360 social workers. 

VA's educational efforts have also included publications. VA's Under 
Secretary for Health has issued five informational letters to VA's 
medical providers offering guidance on OEF-and OIF-related topics. The 
topics of these letters include the long-term effects of heat-related 
illnesses and the long-term effects of using an antimalarial drug. In 
addition, VA's War-Related Illness and Injury Study Centers have 
produced publications providing information for combat veterans and 
providers on topics such as management of chronic pain and the effects 
of exposure to depleted uranium.[Footnote 29] 

VA's War-Related Illness and Injury Study Centers have also provided 
educational activities and clinical tools to help medical professionals 
treat OEF and OIF servicemembers and veterans. In 2004 and 2005 the 
centers reported that they held three conferences, with a total 
attendance of more that 450 health care providers, including 
physicians, nurses, and social workers, that addressed such topics as 
physical and mental health issues, infectious disease issues, and 
health care services provided by VA. They also held six workshops from 
2003 through 2005 on topics such as patient-provider communication and 
the recognition and treatment of undiagnosed illnesses, and established 
Web sites that provide links to their publications and to other sources 
of education for medical providers. 

VA has also developed various clinical tools to enhance the ability of 
its providers and other staff to be aware of and responsive to the 
needs of OEF and OIF servicemembers and veterans. For example, VA has 
added reminder screens to its electronic medical records that pop up 
when a patient's record is opened if the veteran served in the military 
after September 11, 2001. These screens prompt providers to ask 
questions about medical and psychological issues related to OEF and OIF 
veterans, such as infectious diseases and depression. The screens 
continue to pop up each time the patient's medical record is opened 
until the information requested is entered into that record. The pop-up 
reminder screens were the subject of one of the informational letters 
issued to VA staff. Further, VA and DOD developed 25 guidelines for 
clinical practice,[Footnote 30] which can be viewed on a VA Web 
site.[Footnote 31] VA officials stated that any of the guidelines may 
be used for OEF and OIF servicemembers and veterans depending on their 
needs. Finally, VA's National Center for Post- Traumatic Stress 
Disorder and DOD developed the Iraq War Clinician Guide. It addresses 
the needs of veterans of the Iraq war and is available on a VA Web 
site.[Footnote 32] 

Agency Comments and Our Evaluation: 

VA and DOD reviewed a draft of this report and provided written 
comments, which appear in enclosures I and II respectively. VA 
concurred with the information presented in our draft report. It also 
stated that PRCs' access to DOD's electronic medical records has been a 
significant challenge for VA in accomplishing its mission. VA further 
commented that it is justifiably proud of the accomplishments of its 
dedicated staff in successfully responding to the often overwhelming 
transitional needs of these young servicemembers and their families. 
DOD commented that the report portrays the numerous efforts that have 
been made to improve the efficacy of programs designed to ensure a 
smooth transition and continuity of care as servicemembers transition 
back and forth between DOD and VA health care systems. 

DOD commented that the statements in the draft report concerning its 
lack of a systemwide approach to electronic medical record management 
and the inability of providers throughout DOD's health care system to 
access medical records is completely inaccurate. Our statements are not 
inaccurate. While our draft report recognizes DOD's long-standing 
ongoing efforts to achieve the capability to electronically share the 
complete medical record, we did not find that this capability exists 
yet at DOD. For example, in March 2006 the Chief Information Officer at 
the National Naval Medical Center explained to us that MTFs did not 
have access to electronic medical records at other MTFs across the 
United States. He told us that while information could be shared among 
providers linked by a local area network, those providers could not 
electronically access medical records from other local area networks. 
Specifically, he noted that providers at Walter Reed Army Medical 
Center and the National Naval Medical Center can access each other's 
medical records electronically, but they cannot access medical records 
from Landstuhl Regional Medical Center in Germany or from MTFs in San 
Antonio, Texas. He acknowledged that DOD's Armed Forces Health 
Longitudinal Technology Application (AHLTA)--a comprehensive electronic 
health record--will allow providers to access medical information. In 
its comments, DOD also cited the access that AHLTA will provide. 
However, DOD documentation that describes the system states that it is 
for outpatient care--only one part of the complete medical record. VA 
providers treating OEF and OIF servicemembers are in need of 
information concerning the inpatient care--not just the outpatient 
care--that servicemembers received at DOD. Furthermore, AHLTA cannot be 
accessed by all of DOD's providers. In its comments on our draft report 
DOD stated that AHLTA is not operational at 19 percent of DOD's MTFs 
and that full deployment is not expected until December 2006. In 
comparison, VA's system allows the patient's complete medical record to 
be accessed from any VA medical facility. 

In its comments, DOD also mentioned that a section of our draft report 
that described the actions VA has taken to facilitate the transition of 
care from DOD to VA is misleading. However, the section is an accurate 
presentation of VA initiatives as presented to us by VA and as observed 
during our audit work. Furthermore, DOD stated that it transmits 
certain medical information to VA on a monthly basis, although VA 
providers told us they need ready electronic access to current medical 
record information for the seriously injured OEF and OIF 
servicemembers. We believe that in order to plan and begin appropriate 
treatment immediately upon a servicemember's arrival at a PRC, medical 
record information is best provided through direct electronic access, 
not through monthly transmissions. Our draft report recognized the 
technical advances that VA has made in that it has the capability to 
electronically share the complete medical record of each of its 
beneficiaries among all its providers at all its medical facilities. 
This means that all medical services provided by VA to its 
beneficiaries--including information such as outpatient or inpatient 
procedures, pharmacy, or radiology notes--are included in VA's 
electronic record. 

VA and DOD provided technical comments that we incorporated where 
appropriate. 

As agreed with your office, unless you publicly announced its contents 
earlier, we plan no further distribution of this report until 30 days 
after its report date. We will then send copies of this report to the 
Secretaries of Veterans Affairs and Defense and appropriate 
congressional committees. We will also make copies available to others 
on request. In addition, the report will be available at no charge on 
GAO's Web site at [Hyperlink, http://www.gao.gov]. 

If you or your staff have any questions, please contact me at (202) 512-
7101 or bascettac@gao.gov. Contact points for our Offices of 
Congressional Relations and Public Affairs may be found on the last 
page of this report. GAO staff who made major contributions to this 
report are Michael T. Blair, Jr., Assistant Director; Cynthia Forbes; 
Roseanne Price; Shannon Slawter; and Cherie' Starck. 

Sincerely yours, 

Signed by: 

Cynthia A. Bascetta: 
Director, Health Care: 

Enclosures - 2: 

Comments from the Department of Veterans Affairs: 

The Deputy Secretary Of Veterans Affairs: 
Washington, D.C.: 

June 19, 2006: 

Ms. Cynthia A. Bascetta: 
Director: 
Health Care Team: 
U. S. Government Accountability Office: 
441 G Street, NW: 
Washington, DC 20548: 

Dear Ms. Bascetta: 

The Department of Veterans Affairs (VA) has reviewed the Government 
Accountability Office's (GAO) draft report, VA AND DOD HEALTH CARE: 
Efforts to Provide Seamless Transition of Care for OEF and OIF 
Servicemembers and Veterans (GAO 06-794R) and concurs with the 
information as presented. Your report cites many of the initiatives 
that VA has implemented to assure that Operation Enduring Freedom and 
Operation Iraqi Freedom (OEF/OIF) servicemembers receive timely access 
to benefits and high quality health care and that their transition from 
the military to VA is efficient and compassionate. VA and the 
Department of Defense (DoD) have established a collaborative 
relationship to respond to the special needs of these soldiers and 
their families. 

As GAO reports, seamless transition efforts, particularly for seriously 
injured combat veterans, rank among VA's highest priorities. The 
Veterans Health Administration (VHA) has taken the lead in expanding 
outreach and case management efforts, to facilitate medical treatment 
and rehabilitation in our polytrauma rehabilitation centers (PRCs). VHA 
is also developing educational activities and clinical tools to assure 
that VA clinical staff has the information it requires to recognize the 
complex challenges inherent in the types of injuries these veterans 
sustain. Nevertheless, VHA's emphasis continues to focus on ongoing 
improvement recognizing that VHA must maintain the flexibility 
necessary to adapt to changing demand. As part of VHA's efforts to 
monitor its effectiveness, the Office of Seamless Transition is 
implementing a quality assurance program designed to assess VHA's 
program through in-depth review of medical records for patients 
transferred from military facilities to VA facilities. Because the 
program is still in the early developmental stages, data collection, 
aggregation and reporting processes are still being refined. We 
anticipate that valuable trend information will eventually be generated 
to prompt follow-up corrective actions as indicated at the national and 
local levels. 

I agree with GAO that our PRCs' access to DoD electronic medical 
records has been a significant challenge for VA in accomplishing our 
mission. Our program managers continue to work in close coordination 
with DoD to resolve remaining obstacles. As reported, both the Richmond 
and Tampa PRCs can now access the electronic records from Walter Reed 
Army Medical Center and Bethesda National Naval Medical Center. The 
Minneapolis and Palo Alto PRCs have requested the same access, and VHA 
is pursuing vigorously full record sharing capability with appropriate 
Army and Navy officials. I anticipate that successful data transfer 
will be available in the near future. 

VHA is justifiably proud of the accomplishments of its dedicated staff 
in successfully responding to the often overwhelming transitional needs 
of these young servicemembers and their families. I am personally 
committed to assure that every resource will be used to maintain the 
highest levels of support in any way that is needed. GAO's report has 
been very helpful in highlighting our strengths and priorities, and I 
appreciate the opportunity to comment on it. VA is also providing 
technical comments separately. 

Sincerely yours, 

Signed by: 

Gordon H. Mansfield: 

Comments from the Department of Defense: 

The Assistant Secretary Of Defense: 
Washington, D. C. 20301-1200: 
 
Ms. Cynthia Bascetta: 
Director, Health Care: 
U.S. Government Accountability Office: 
441 G. Street, N.W. 
Washington, DC 20548: 

Jun 15 2006: 

Dear Ms. Bascetta: 

This is the Department of Defense (DoD) response to the Government 
Accountability Office (GAO) draft report, GAO 06-749R, "VA And DOD 
Health Care: Efforts to Provide Seamless Transition of Care for OEF and 
OIF Servicemembers and Veterans," dated June 2, 2006 (GAO Code 290463). 

The Department appreciates the opportunity to provide the attached 
comments on the draft report. 

Please direct any questions to my points of contact on this matter, Mr. 
Kenneth Cox (functional) at (703) 681-0039, ext. 3602 and Mr. Gunther 
J. Zimmerman (Audit Liaison) at (703) 681-3492, ext. 4065. 

Sincerely, 

Signed by: 

William Winkenwerder, Jr., MD: 

Enclosures: 

1. Overall Comments 
2. Technical Comments: 

GAO Draft Report -Dated June 2, 2006 GAO Code - 290463/GAO-06-794R: 

"VA And Dod Health Care: Efforts to Provide Seamless Transition of Care 
for OEF and OIF Service members and Veterans" 

Department Of Defense Comments: 

This draft report provides a review of the Department of Veterans 
Affairs' (VA) and Department of Defense's (DoD) efforts to date to 
ensure continuity of care for service members injured in Operations 
Enduring Freedom and Iraqi Freedom. 

Overall Comments: 

* The report portrays the numerous efforts that have been made to 
improve the efficacy of programs designed to ensure a smooth transition 
and continuity of care as wounded and injured service members 
transition back and forth between the Military Health System and the 
Veterans Health Administration. However, the report does contain 
several inaccuracies that are addressed in the attached technical 
comments. Key examples are: 

* The report states that "In addition, DoD does not have a system-wide 
approach to electronic medical record management since the information 
is maintained and stored in individual MTFs, or in some locations, in 
networks that service multiple MTFs within a small geographical area. 
Under DoD's approach, medical information cannot be accessed by 
providers throughout DoD's health care system." 

This statement is completely inaccurate. It does not recognize the 
current state of DoD's electronic health record development and 
implementation. DoD began implementation of a standards-based, 
comprehensive electronic health record, called AHLTA, in January 2004. 
AHLTA generates, maintains and provides worldwide, secure, round-the- 
clock online access to health records on our 9.2 million beneficiaries. 
Authorized health care providers can access patient information 
regardless of the location where care was provided, as evident during 
Hurricane Katrina. A key component to AHLTA is the centralized Clinical 
Data Repository (CDR) which contains electronic clinical records for 
over 8.04 million beneficiaries. As of June 2, 2006, AHLTA has been 
implemented at 113 of 139 planned Medical Treatment Facilities with 
48,447 of 63,000 total users fully trained to include 16,359 health 
care providers. Deployment to all planned facilities is scheduled for 
completion in December 2006. To date, AHLTA has processed over 80,958 
patient encounters daily for a cumulative total of over 21 million 
outpatient encounters, and continues to grow daily. At the time of this 
study, AHLTA was being implemented at Walter Reed Army Medical Center 
(September 2005 - April 2006) and National Naval Medical Center 
Bethesda (September 2005 - May 2006). 

* The report cites "VA has taken a number of actions to facilitate the 
transition of medical and rehabilitation care for service members who 
have been seriously injured in OEF and OIF and are being transferred 
between DoD and VA medical facilities. These actions focus on 
establishing and expanding internal initiatives for providing care to 
this population as well as VA's efforts to electronically share medical 
records with DoD". 

This statement is misleading. DoD transmits to VA on a monthly basis: 
laboratory results, radiology results, outpatient pharmacy data, 
allergy information, discharge summaries, consult reports, admission, 
disposition and transfer information, elements of the standard 
ambulatory data records and demographic data on separated service 
members. VA providers and benefits specialists access this data daily 
for use in the delivery of healthcare and claims adjudication. DoD has 
transmitted messages to the Federal Health Information Exchange (FHIE) 
data repository on more than 3.5 million unique retired or discharged 
Service members. This number grows as health information on recently 
separated Service members is extracted and transferred to VA. 
Bidirectional Health Information Exchange (BHIE) is a joint DoD and VA 
initiative which enables real-time sharing of allergy, outpatient 
pharmacy, demographic, laboratory and radiology data between DoD BHIE 
sites and all VA Treatment Facilities for patients treated in both DoD 
and VA. As of May 2006, BHIE is operational at 14 sites (see first 
technical note, referring to p. 7). 

DoD also sends electronic pre-and post-deployment health assessment 
information to the VA. The initial historical data extraction for 
separated Service members was completed in July 2005 resulting in 
approximately 400,000 pre-and post-deployment health assessments being 
sent to the FHIE data repository at the VA Austin Automation Center. 
Monthly transmission of electronic pre-and post-deployment health 
assessment data to the FHIE data repository began in September 2005 and 
has continued each month since then. VA providers began accessing the 
data in December 2005. Beginning in March 2006, and continuing monthly, 
pre-and post-deployment health assessment data on Reserve and National 
Guard members, who were deployed and are now demobilized, is also being 
transferred to the FHIE data repository. 

* The report states "According to VA officials, the main barrier to PRC 
medical providers' getting real-time access to medical records centered 
on DoD's interpretation of Health Insurance Portability and 
Accountability Act of 1996 (HIPAA) and the HIPAA Privacy Rule. The 
HIPAA Privacy Rule permits DoD and VA to share service members' health 
information under certain circumstances, such as for purposes of 
treatment or if the individual signs a proper authorization. However, 
DoD officials told us they initially were reluctant to provide this 
access to VA because they were concerned that VA would have access to 
health information of all service members, not only the information of 
those being transferred to the PRC for treatment." 

DoD applies stringent measures to ensure security and privacy of 
patient health information, to include the use of access control 
technology, strict role-based password protection, auditing of user 
actions, encryption, firewalls, de-identification of patient 
identifiable data during testing, certifications and accreditations, 
anti-viral software, network and physical security, training and 24 
hour intrusion detection monitoring and tracking. Working within these 
measure's, DoD continues to explore with the VA and other industry 
partners, such things as the use of virtual private networks and point- 
to-point networks to securely transmit health information or provision 
of direct access where appropriate. 

These issues are not unique to the DoD or VA. The Department of Health 
and Human Services, Office of National Coordinator, and American Health 
Information Community are grappling with these very issues regarding 
the establishment of a national health infrastructure which will 
support the use of electronic medical records and subsequent data 
exchange. Security and privacy of data is a key aspect of their 
considerations. The DoD and VA are actively engaged in these 
discussions. 

The recent massive VA information security breach that contained 
considerable information on active duty military service members 
highlights the critical importance of getting the appropriate security 
procedures in place before plunging forward. 

Related GAO Products: 

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

VA and DOD Health Care: VA Has Policies and Outreach Efforts to Smooth 
Transition from DOD Health Care, but Sharing of Health Information 
Remains Limited. GAO-05-1052T. Washington, D.C.: September 28, 2005. 

Computer-Based Patient Records: VA and DOD Made Progress, but Much Work 
Remains to Fully Share Medical Information. GAO-05-1051T. Washington, 
D.C.: September 28, 2005. 

Military and Veterans' Benefits: Improvements Needed in Transition 
Assistance Services for Reserves and National Guard. GAO-05-844T. 
Washington, D.C.: June 29, 2005. 

Military and Veterans' Benefits: Enhanced Services Could Improve 
Transition Assistance for Reserves and National Guard. GAO-05-544. 
Washington, D.C.: May 20, 2005. 

DOD and VA: Systematic Data Sharing Would Help Expedite Servicemembers' 
Transition to VA Services. GAO-05-722T. Washington, D.C.: May 19, 2005. 

Vocational Rehabilitation: VA Has Opportunities to Improve Services, 
but Faces Significant Challenges. GAO-05-572T. Washington, D.C.: April 
20, 2005. 

VA Disability Benefits and Health Care: Providing Certain Services to 
the Seriously Injured Poses Challenges. GAO-05-444T. Washington, D.C.: 
March 17, 2005. 

Vocational Rehabilitation: More VA and DOD Collaboration Needed to 
Expedite Services for Seriously Injured Servicemembers. GAO-05-167. 
Washington, D.C.: January 14, 2005. 

Computer-Based Patient Records: Sound Planning and Project Management 
Are Needed to Achieve a Two-Way Exchange of VA and DOD Health Data. GAO-
04-402T. Washington, D.C.: March 17, 2004. 

Computer-Based Patient Records: Short-Term Progress Made, but Much Work 
Remains to Achieve a Two-Way Data Exchange Between VA and DOD Health 
Systems. GAO-04-271T. Washington, D.C.: November 19, 2003. 

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

(290463): 

FOOTNOTES 

[1] DOD's Contingency Tracking System Deployment File for Operations 
Enduring Freedom and Iraqi Freedom reported that as of March 31, 2006, 
the total number of servicemembers ever deployed was 1,312,221. 

[2] OEF, which began in October 2001, supports combat operations in 
Afghanistan and other locations, and OIF, which began in March 2003, 
supports combat operations in Iraq and other locations. 

[3] DOD provides health care through TRICARE--a regionally structured 
program that uses civilian contractors to maintain provider networks to 
complement health care services provided at military treatment 
facilities. 

[4] The Veterans' Administration and Department of Defense Health 
Resources Sharing and Emergency Operations Act, Pub. L. No. 97-174,  
4(a), 96 Stat. 70, 74-75. 

[5] Most servicemembers receive medical care from DOD providers. 
However, DOD does not typically provide long-term rehabilitative 
services and looks to VA to be a provider of these services. 

[6] The Veterans Health Programs Improvement Act of 2004, Pub. L. No. 
108-422,  302, 118 Stat. 2379, 2383-86, mandated that VA establish 
centers for research, education, and clinical activities related to 
complex multiple trauma associated with combat injuries. In response to 
that mandate, VA established PRCs at four VA medical facilities with 
expertise in traumatic amputation, spinal cord injury, traumatic brain 
injury, and blind rehabilitation. The PRCs address the rehabilitation 
needs of the combat injured in one setting and in a coordinated manner. 

[7] GAO, VA and DOD Health Care: VA Has Policies and Outreach Efforts 
to Smooth Transition from DOD Health Care, but Sharing of Health 
Information Remains Limited, GAO-05-1052T (Washington, D.C.: Sept. 28, 
2005). Also see Related GAO Products at the end of this report. 

[8] VA provides briefings at hundreds of MTFs. We attended briefings at 
two judgmentally selected installations--the Naval Station Norfolk, 
Norfolk, Virginia, and Fort Benning Army Base, Columbus, Georgia. 

[9] Although OEF began in October 2001, the earliest recorded date that 
a servicemember injured in OEF was admitted to a PRC for treatment was 
January 7, 2002. 

[10] Traumatic brain injuries may cause problems with cognition 
(concentration, memory, judgment, and mood), movement (strength, 
coordination, and balance), sensation (tactile sensation and vision), 
and emotion (instability and impulsivity). 

[11] National Science and Technology Council, A National Obligation: 
Planning for Health Preparedness for and Readjustment of the Military, 
Veterans, and Their Families After Future Deployments, Presidential 
Review Directive 5 (Washington, D.C.: Executive Office of the 
President, Office of Science and Technology Policy, August 1998). 

[12] GAO, Computer-Based Patient Records: VA and DOD Made Progress, but 
Much Work Remains to Fully Share Medical Information, GAO-05-1051T 
(Washington, D.C.: Sept. 28, 2005). 

[13] See [Hyperlink, http://www.seamlesstransition.va.gov]. 

[14] See [Hyperlink, http://www1.va.gov/opa/feature/amervet/index.htm]. 

[15] See [Hyperlink, http://www.pentagonchannel.mil]. 

[16] In addition to outlining DOD's and VA's responsibilities in the 
transfer process, the MOA also established the reimbursement rate 
between the two departments for inpatient care that VA would provide. 

[17] Case management includes assessment of the individual's health 
care needs, care planning and implementation, referral coordination, 
monitoring, and periodic reassessment of the individual's health care 
needs. 

[18] Five MTFs were originally selected because they received most of 
the OEF and OIF casualties. These facilities were Walter Reed Army 
Medical Center (Washington, D.C.), Brooke Army Medical Center (San 
Antonio, Texas), Dwight David Eisenhower Army Medical Center (Augusta, 
Georgia), Madigan Army Medical Center (Tacoma, Washington), and the 
National Naval Medical Center (Bethesda, Maryland). In 2004 and 2005, 
three additional MTFs--Darnall Army Community Hospital (Fort Hood, 
Texas), Evans Army Community Hospital (Fort Carson, Colorado), and the 
Naval Hospital Camp Pendleton (Camp Pendleton, California)--were added 
to care for returning OEF and OIF servicemembers. 

[19] According to VA, patients remain in pending status until DOD 
determines that the patient is ready for transfer to a VA facility and 
VA determines the patient's medical condition is stable. 

[20] The Veterans Benefits Administration provides benefits and 
services, such as disability compensation, to veterans. The Veterans 
Health Administration's primary responsibility is the delivery of 
health care to veterans. 

[21] Blood filters are filters that screen blood to remove clots that 
could result in death. 

[22] VA officials in attendance included staff from the PRCs and the 
Seamless Transition Office. DOD officials in attendance included staff 
from Walter Reed Army Medical Center; the National Naval Medical 
Center; Brooke Army Medical Center; Wilford Hall Medical Center; Army 
Institute for Surgical Research; Landstuhl Regional Medical Center in 
Germany; and combat medical units located in Balad and Baghdad, Iraq. 

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

[24] GAO, 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.: Mar. 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, 
GAO-04-271T (Washington, D.C.: Nov. 19, 2003); and GAO-05-1051T. 

[25] Pub. L. No. 104-191, 110 Stat. 1936 (1996). 

[26] The Privacy Rule, which became effective on April 14, 2001, 
specifies how individually identifiable health information may be used 
and disclosed by covered entities, which include health plans, health 
care clearinghouses, and certain health care providers. See 45 C.F.R. 
 164.500(a), 164.502 (2005). Both TRICARE and the VA health care 
system are health plans. See 45 C.F.R.  160.103 (2005). 

[27] This initiative is a unique undertaking by the four PRCs, Walter 
Reed Army Medical Center, and the National Naval Medical Center. It is 
distinct from VA's and DOD's Bidirectional Health Information Exchange. 

[28] The remaining 67 patients did not need follow-up outpatient 
appointments because they were still patients in the PRC; had been 
transferred to another inpatient facility, such as an MTF or VA long- 
term care facility; or did not need follow-up medical care. 

[29] In May 2001, VA established the two War-Related Illness and Injury 
Study Centers, one in Washington, D.C., and one in East Orange, New 
Jersey. The mission of these centers includes providing health-related 
educational services to veterans and health care professionals. 

[30] Clinical practice guidelines are recommendations for treating 
specific diseases or conditions. 

[31] See [Hyperlink, http://www.oqp.med.va.gov/cpg/cpg.htm]. 

[32] See [Hyperlink, http://www.ncptsd.va.gov/war/guide/index.html]. 

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