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2003 President's Task Force Recommendations on Collaboration and 
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30, 2008. 

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April 30, 2008: 

The Honorable Daniel K. Akaka: 
Chairman: 
Committee on Veterans' Affairs: 
United States Senate: 

Subject: VA and DOD Health Care: Progress Made on Implementation of 
2003 President's Task Force Recommendations on Collaboration and 
Coordination, but More Remains to Be Done: 

Dear Mr. Chairman: 

Improving collaboration and health resource sharing between the 
Department of Veterans Affairs (VA) and the Department of Defense (DOD) 
has been the focus of numerous efforts by Congress and the executive 
branch for more than two decades. In 1982, Congress passed the 
Veterans' Administration and Department of Defense Health Resources 
Sharing and Emergency Operations Act (Sharing Act), which authorized VA 
and DOD health care facilities to partner and enter into sharing 
agreements to buy, sell, and barter medical and support 
services.[Footnote 1] Since then, Congress has passed additional 
legislation to continue to promote VA and DOD health resource 
sharing.[Footnote 2] However, in previous work we have pointed out 
continuing barriers to such efforts, including incompatible computer 
systems that affect the exchange of patient health information, 
inconsistent reimbursement and budgeting policies, and burdensome 
processes for approving agreements between the departments.[Footnote 3] 

On May 28, 2001, the President established the 15-member President's 
Task Force to Improve Health Care Delivery for Our Nation's Veterans. 
The task force's mission was to identify ways to improve coordination 
and sharing between VA and DOD in order to improve health care for 
servicemembers and veterans.[Footnote 4] The task force reviewed 
barriers and challenges in several areas related to coordination, 
including leadership, transition to veteran status, and improving 
quality of health care. In May 2003, it made recommendations to VA and 
DOD to increase collaboration and coordination between the two 
departments to improve health care delivery.[Footnote 5] The task force 
also recommended that the administration take action through the 
Department of Health and Human Services (HHS) to help improve VA and 
DOD collaboration, and that Congress take additional action to improve 
such collaboration. Other more recent task force and commission reports 
have voiced similar concerns and identified more areas for improvement. 
These reports include the 2007 Task Force on Returning Global War on 
Terror Heroes report,[Footnote 6] the 2007 President's Commission on 
Care for America's Returning Wounded Warriors "Dole-Shalala 
report,"[Footnote 7] and the 2007 Veterans' Disability Benefits 
Commission report.[Footnote 8] 

You asked us to examine the status of VA and DOD's efforts in 
implementing the 2003 task force recommendations. Specifically, this 
report describes the extent to which VA and DOD have implemented the 
recommendations of the 2003 President's Task Force to Improve Health 
Care for Our Nation's Veterans related to collaboration and 
coordination. 

The scope of this report is the 20 recommendations in the first four 
chapters of the task force's report, which focus on increased 
collaboration and coordination.[Footnote 9] To describe the extent to 
which VA and DOD have implemented the task force recommendations, we 
collected information on the departments' related activities by 
reviewing documents provided by VA and DOD--including the departments' 
written responses to our questions, annual reports, and other 
documents; interviewing department officials; reviewing related task 
force and commission reports; and reviewing our prior work on related 
subjects. We examined information provided by VA and DOD officials and 
compared information provided by the departments with relevant findings 
from our prior reports. Although some of the task force recommendations 
had multiple parts, we considered each recommendation as a whole, 
rather than addressing a recommendation's parts individually. A few 
recommendations contained deadlines that have lapsed, and we have 
described the departments' actions to date without consideration of 
these deadlines. We conducted our work from July 2007 through April 
2008 in accordance with generally accepted government auditing 
standards. 

In summary, we found that VA and DOD have made progress in implementing 
the task force recommendations, but more remains to be done to fully 
implement all task force recommendations. Seven of the recommendations 
have been fully implemented and 11 have been partially implemented. We 
could not determine the status of 1 because of insufficient 
information, and 1 does not require VA or DOD action. 

* Fully implemented. Four out of the seven recommendations we found to 
be fully implemented have been carried out through the Joint Executive 
Council (JEC), an interagency leadership committee of VA and DOD 
officials.[Footnote 10] The JEC issues annual reports on its 
activities, has developed joint health care outcome metrics, and has 
identified functional areas to reengineer business processes and 
information technology to enhance care, as recommended. It also 
regularly uses civilian consultants in its collaborative efforts, as 
recommended. In addition, the departments have fully implemented three 
other task force recommendations that address expanding collaboration 
to collect and maintain data on servicemembers' occupational exposure 
and hazards; sharing routinely information on servicemembers' 
assignment history, occupational exposures, and injuries; and 
conducting continuous health surveillance and research on the long-term 
health consequences of military service. 

* Partially implemented. These 11 recommendations address a variety of 
issues, such as developing interoperable electronic medical records, 
implementing a mandatory single physical examination when a 
servicemember is separating from military service, and integrating 
pharmacy initiatives. The departments have made progress in 
implementing these recommendations, but have more to do to fully 
implement them. 

* Unable to determine. As of April 2008, VA and DOD had not provided 
sufficient information for us to determine the status of one 
recommendation. The recommendation requires that the departments 
address staffing shortfalls, develop consistent clinical scopes of 
practice for nonphysician providers, and ensure interfacing 
credentialing systems. We were not able to determine the status of this 
recommendation because VA and DOD did not provide sufficient 
information on their efforts to address staffing shortfalls and to 
develop consistent clinical scopes of practice for nonphysician 
providers. 

* No action required. One recommendation requires that the 
administration direct HHS to declare VA and DOD a single health care 
system for purposes of facilitating the exchange of health information 
in accordance with the Health Insurance Portability and Accountability 
Act (HIPAA) Privacy Rule.[Footnote 11] According to VA, the departments 
have sufficient authority for data sharing as permitted by HIPAA 
without becoming one single entity.[Footnote 12] In addition, VA and 
DOD have implemented a data-sharing memorandum of understanding (MOU) 
that outlines agreed-upon authorities for sharing protected health 
information as permitted by HIPAA. 

See table 1 for the implementation status of the task force 
recommendations. See enclosure I for a detailed description of the 
recommendations, the implementation status, the actions taken by VA and 
DOD, and the actions remaining to fully implement the task force 
recommendations. 

Table 1: Status of 2003 President's Task Force Recommendations Related 
to VA and DOD Collaboration and Coordination: 

Recommendation, by type and number: Reporting: 1.1; 
Recommendation, by type and number: Reporting: Require the interagency 
leadership committee to annually report to VA and DOD Secretaries on 
task force recommendations and activities; 
Status: Fully Implemented. 

Recommendation, by type and number: Leadership, collaboration, and 
oversight: 2.1; 
Recommendation, by type and number: Leadership, collaboration, and 
oversight: Broaden the interagency leadership committee charter beyond 
health care and have the committee consider using civilian consultants 
for collaboration; 
Status: Fully Implemented. 

Recommendation, by type and number: Leadership, collaboration, and 
oversight: 2.2; 
Recommendation, by type and number: Leadership, collaboration, and 
oversight: Use a joint strategic planning and budgeting process; 
Status: Partially Implemented. 

Recommendation, by type and number: Leadership, collaboration, and 
oversight: 2.3; 
Recommendation, by type and number: Leadership, collaboration, and 
oversight: Develop joint health care outcome metrics; 
Status: Fully Implemented. 

Recommendation, by type and number: Seamless transition to veteran 
status: 3.1; 
Recommendation, by type and number: Seamless transition to veteran 
status: Seamless transition to veteran status: Develop interoperable 
electronic medical records; 
Status: Partially Implemented. 

Recommendation, by type and number: Seamless transition to veteran 
status: 3.2; 
Recommendation, by type and number: Seamless transition to veteran 
status: Require the administration to direct the Department of Health 
and Human Services (HHS) to declare that VA and DOD are a single health 
care system for Health Insurance Portability and Accountability Act 
(HIPAA) purposes; 
Status: No action needed. 

Recommendation, by type and number: Seamless transition to veteran 
status: 3.3; 
Recommendation, by type and number: Seamless transition to veteran 
status: Implement a mandatory single physical examination for 
servicemembers separating from military service and electronic 
transmission of separation information; 
Status: Partially Implemented. 

Recommendation, by type and number: Seamless transition to veteran 
status: 3.4; 
Recommendation, by type and number: Seamless transition to veteran 
status: Facilitate a seamless transition to veteran status; 
Status: Partially Implemented. 

Recommendation, by type and number: Seamless transition to veteran 
status: 3.5; 
Recommendation, by type and number: Seamless transition to veteran 
status: Collaborate on collecting and maintaining information on 
servicemember exposure and hazards; 
Status: Fully Implemented. 

Recommendation, by type and number: Seamless transition to veteran 
status: 3.6; 
Recommendation, by type and number: Seamless transition to veteran 
status: Share routinely information on servicemember assignment 
history, exposure, and injuries; 
Status: Fully Implemented. 

Recommendation, by type and number: Seamless transition to veteran 
status: 3.7; 
Recommendation, by type and number: Seamless transition to veteran 
status: Conduct surveillance and research on long-term health 
consequences of military service; 
Status: Fully Implemented. 

Recommendation, by type and number: Removing barriers to collaboration: 
4.1; 
Recommendation, by type and number: Removing barriers to collaboration: 
Revise health care system organizational structures to improve 
coordination and enhance care; 
Status: Partially Implemented. 

Recommendation, by type and number: Removing barriers to collaboration: 
4.2; 
Recommendation, by type and number: Removing barriers to collaboration: 
Enhance local and regional authority, accountability, and incentives 
for collaborative health care efforts; 
Status: Partially Implemented. 

Recommendation, by type and number: Removing barriers to collaboration: 
4.3; 
Recommendation, by type and number: Removing barriers to collaboration: 
Integrate pharmacy initiatives; 
Status: Partially Implemented. 

Recommendation, by type and number: Removing barriers to collaboration: 
4.4; 
Recommendation, by type and number: Removing barriers to collaboration: 
Allow shared patients to obtain prescriptions at both VA and DOD 
pharmacies; 
Status: Partially Implemented. 

Recommendation, by type and number: Removing barriers to collaboration: 
4.5; 
Recommendation, by type and number: Removing barriers to collaboration: 
Standardize medical supplies and equipment identification for joint 
acquisition; 
Status: Partially Implemented. 

Recommendation, by type and number: Removing barriers to collaboration: 
4.6; 
Recommendation, by type and number: Removing barriers to collaboration: 
Identify functional areas where the departments have similar 
requirements for reengineering business processes and information 
technology to enhance care; 
Status: Fully Implemented. 

Recommendation, by type and number: Removing barriers to collaboration: 
4.7; 
Recommendation, by type and number: Removing barriers to collaboration: 
Implement facility lifecycle management practices; 
Status: Partially Implemented. 

Recommendation, by type and number: Removing barriers to collaboration: 
4.8; 
Recommendation, by type and number: Removing barriers to collaboration: 
Develop joint policies and lessons learned on joint ventures; 
Status: Partially Implemented. 

Recommendation, by type and number: Removing barriers to collaboration: 
4.9; 
Recommendation, by type and number: Removing barriers to collaboration: 
Address staffing shortfalls, develop consistent clinical scopes of 
practice for nonphysician providers, and ensure interfacing 
credentialing systems; 
Status: Unable to determine. 

Source: GAO analysis of VA and DOD information and President's task 
force report. 

[End of table] 

We provided draft copies of this report to VA and DOD for review and 
comment. VA provided written comments and technical comments, and 
agreed with our findings. DOD provided written comments and agreed with 
our findings provided that we incorporate technical comments that it 
provided. We incorporated the agencies' technical comments as 
appropriate, including comments that changed the implementation status 
of the task force recommendations, updated information, or provided a 
clearer understanding of the actions VA and DOD have taken or actions 
that remain to be taken. VA and DOD comments are reprinted in 
enclosures II and III, respectively. 

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

If you or your staff have questions about this report, please contact 
me at (206) 287-4860 or williamsonr@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 members who made key 
contributions to this report are listed in enclosure IV. 

Sincerely yours, 

Randall B. Williamson: 

Director, Health Care: 

Enclosures - 4: 

Enclosure I: 

VA and DOD Actions Taken and Actions Remaining to Fully Implement the 
2003 President's Task Force Recommendations Related to Collaboration 
and Coordination: 

Table 2: 

Recommendation, by type and number: Reporting: 1.1: The interagency 
leadership committee should, on an annual basis, report to the 
Secretaries on the status of implementing its collaboration and sharing 
initiatives and the recommendations in this Final Report, together with 
any other matters that the committee deems appropriate. Within 60 days 
after receipt, the Secretaries shall transmit the report, together with 
any related comments, to the President; 
Status: Fully Implemented; 
Action taken: The VA/ DOD Joint Executive Council (JEC), first 
established as the interagency leadership committee in 2002,[A] issues 
an annual report describing progress on VA and DOD collaborative 
efforts. According to DOD, the JEC annual report is consistent with the 
President's task force recommendations in that it addresses the same 
key issues; 
Action remaining: None. 

Recommendation, by type and number: Leadership, collaboration, and 
oversight: 2.1: Congress should amend the fiscal year 2003 National 
Defense Authorization Act to create a broader charter beyond health 
care for the interagency leadership committee. Additionally, 
consideration should be given to using civilian experts as consultants 
to the committee to bring in new perspectives regarding collaboration 
and sharing; 
Status: Fully Implemented; 
Action taken: Congress expanded the scope of the JEC to benefits and 
services, generally, through the National Defense Authorization Act 
(NDAA) for Fiscal Year 2004.[B] VA and DOD have used civilian experts 
as consultants in many areas--for example, a JEC working group 
consulted with a civilian company on information systems and 
technology. VA and DOD officials also told us that they will be using 
civilian subject matter experts to assist each of the JEC working 
groups in developing performance measures and targets for the Joint 
Strategic Plan (JSP); 
Action remaining: None. 

Recommendation, by type and number: Leadership, collaboration, and 
oversight: 2.2: The departments should consistently utilize a joint 
strategic planning and budgeting process for collaboration and sharing 
to institutionalize the development of joint objectives, strategies, 
and best practices, along with accountability for outcomes; 
Status: Partially Implemented; 
Action taken: The JEC has developed a new JSP each year since 2003. The 
JSP is reviewed, updated as necessary, and included in the annual JEC 
report. According to DOD, the JSP outlines actionable objectives, 
assigns accountability, and establishes performance targets. In 
addition, VA told us that the departments recently held a joint budget 
review under the auspices of the Senior Oversight Committee (SOC) in 
order to determine budgetary needs associated with recommendations and 
statutory requirements related to collaboration activities. Further, 
according to VA, the departments will periodically review joint 
collaboration requirements and associated budgets in order to ensure 
recommendations and statutory requirements are met; 
Action remaining: VA and DOD are not utilizing a joint budgeting 
process, as recommended by the task force. According to the 
departments, they do not have legal authority to submit joint budgets. 
Instead, VA and DOD have begun other efforts to align their health care 
budgets that could facilitate fully implementing this recommendation. 

Recommendation, by type and number: Leadership, collaboration, and 
oversight: 2.3: The departments should jointly develop metrics (with 
indicated accountability) that measure health care outcomes related to 
access, quality, and cost as well as progress toward objectives for 
collaboration, sharing and desired outcomes. In the annual report 
prescribed in recommendation 1.1, the interagency leadership committee 
should include these results and discuss the coming year's goals; 
Status: Fully Implemented; 
Action taken: VA and DOD have jointly developed metrics to measure 
health care outcomes related to access, quality, and cost, as well as 
progress toward objectives for collaboration, sharing, and desired 
outcomes. Such metrics are included in the JSP, which consists of six 
strategic goals accompanied by performance expectations, measurements, 
and timelines.[C] Progress is reported in the JEC annual report, and 
according to the departments, also at bimonthly Health Executive 
Council (HEC) and Benefits Executive Council meetings and quarterly JEC 
meetings; 
Action remaining: None. 

Recommendation, by type and number: Seamless transition to veteran 
status: 3.1: VA and DOD should develop and deploy by fiscal year 2005 
electronic medical records that are interoperable, bidirectional, and 
standards-based; 
Status: Partially Implemented; 
Action taken: Outpatient pharmacy and drug allergy data, but not other 
health care data, are currently electronic, interoperable, 
bidirectional, and standards-based. This computable information is 
exchanged for shared patients at seven sites via the interface between 
the DOD Clinical Data Repository and the VA Health Data Repository 
known as CHDR. VA and DOD are also sharing health data through other 
initiatives in which the data are not computable. For example, the 
Bidirectional Health Information Exchange (BHIE), now operational at 
all VA and DOD sites, does not enable the exchange of data but allows 
clinicians in both departments to view selected medical data on screen 
in real time. With BHIE, the clinicians can view outpatient pharmacy 
data, allergy information, radiology reports, surgical pathology 
reports, microbiology results, cytology reports, laboratory orders, 
chemistry and hematology reports, and at some sites, inpatient 
discharge summaries and/or emergency room notes. The departments have 
teamed to develop the Joint DOD/VA Information Interoperability Plan, 
targeted for approval in August 2008, to guide the development and 
implementation of an interoperable, bidirectional, and standards based 
electronic health record capability for military and veteran 
beneficiaries; 
Action remaining: The departments are not able to exchange all health 
care data as computable medical records that are interoperable, 
bidirectional, and standards-based, as recommended by the task force. 
Further, they have not developed a comprehensive project plan with a 
completion date, which would guide their efforts until the goal of the 
comprehensive, seamless exchange of electronic medical records is 
achieved.[D,E]. 

Recommendation, by type and number: Seamless transition to veteran 
status: 3.2: The administration should direct HHS [the Department of 
Health and Human Services] to declare the two departments to be a 
single health care system for purposes of implementing HIPAA [the 
Health Insurance Portability and Accountability Act] regulations; 
Status: No action needed; 
Action taken: According to VA, the departments have sufficient 
authority for data sharing as permitted by HIPAA without becoming a 
single entity.[F] In addition, VA and DOD have implemented a data-
sharing memorandum of understanding (MOU) that outlines agreed-upon 
authorities for sharing protected health information as permitted by 
HIPAA. VA and DOD officials also told us that the departments are 
sharing data at an unprecedented level and are continuing to expand 
shared access to data; 
Action remaining: None. 

Recommendation, by type and number: Seamless transition to veteran 
status: 3.3: The departments should implement by fiscal year 2005 a 
mandatory single separation physical as a prerequisite of promptly 
completing the military separation process. Upon separation, DOD should 
transmit an electronic DD214 [military discharge document] to VA; 
Status: Partially Implemented; 
Action taken: VA and DOD have established procedures for single 
separation physical examinations and methods to monitor their conduct. 
However, as we noted in a November 2004 report, the agencies face 
challenges in expanding use of single separation physicals, such as 
lack of requirements for separation physical examinations in all 
services and lack of resources.[G] In comments on our November 2004 
report, DOD identified problems with DOD- VA electronic data 
interchange as a barrier to better monitoring of single separation 
physicals. Recently enacted legislation mandates joint DOD-VA 
processes, procedures, and standards for transition of recovering 
servicemembers from DOD to VA, including a process for single 
separation physical examinations.h; DOD and VA are piloting a joint 
disability evaluation process, including a single physical examination. 
For pilot participants, this examination is also intended to serve as 
the single separation examination; According to DOD officials, the 
Defense Integrated Military Human Resources System (DIMHRS) is being 
developed to provide the electronic, computable interface between VA 
and DOD systems for transmittal and use of an electronic DD214. As of 
February 2008, DIMHRS has not been deployed. Plans are for the Army to 
start using DIMHRS in late 2008. The Air Force is planning to begin 
using DIMHRS in early 2009. The Navy and Marine Corps will start using 
DIMHRS at a date to be determined; 
Action remaining: VA and DOD have not fully implemented a mandatory 
single separation physical examination for all servicemembers 
completing their military service, which would be facilitated by 
developing the mandated transition process; The departments have also 
not fully implemented a process for transmitting computable electronic 
DD214s from DOD to VA, as DOD has not completed the development of 
DIMHRS to transmit the information electronically. 

Recommendation, by type and number: Seamless transition to veteran 
status: 3.4: VA and DOD should expand the one-stop shopping process to 
facilitate a more effective seamless transition to veteran status. This 
process should provide, at a minimum: (1) a standard discharge 
examination suitable to document conditions that might indicate a 
compensable condition; (2) full outreach; (3) claimant counseling; (4) 
when appropriate, referral for a compensation and pension examination 
and follow-up claims adjudication and rating; 
Status: Partially Implemented; 
Action taken: For a discussion of the single separation physical 
examination issue, see recommendation 3.3; Under the Transition 
Assistance Program and Disabled Transition Assistance Program, VA 
provides job-search, employment, education, and VA benefits 
information. In fiscal year 2007, VA conducted over 8,000 briefings to 
almost 300,000 servicemembers; According to VA, the department has 
stationed personnel at major military treatment facilities (MTF) to 
help wounded servicemembers as they transition from military to 
civilian life. These include personnel to help servicemembers apply for 
VA disability benefits. Under the DOD-VA disability evaluation pilot, 
DOD Physical Evaluation Board Liaison Officers and VA Military Service 
Coordinators are tasked to assist servicemembers during the disability 
evaluation process. In addition, VA has hired and trained eight Federal 
Recovery Coordinators, as recommended by the Dole-Shalala Commission, 
to help assist wounded, ill, and injured servicemembers at three DOD 
medical facilities; Under its Benefits Delivery at Discharge (BDD) 
program, VA takes disability claims from servicemembers prior to 
discharge and begins to process them. VA and DOD have agreements to 
take such claims at about 140 sites. According to VA, of all original 
disability compensation claims filed within 1 year of discharge, 53 
percent were filed prior to discharge at BDD sites. Under the DOD-VA 
disability evaluation pilot, VA is taking claims from servicemembers 
early in the DOD evaluation process; 
Action remaining: VA and DOD have not expanded the one-stop shopping 
process to create a seamless transition to veteran status for all 
veterans, as recommended by the task force; The streamlined process 
currently being piloted has the potential to expedite VA claims 
processing, with VA taking claims and making disability rating 
decisions for some servicemembers prior to discharge.[I] While DOD and 
VA plan to expand the pilot beyond its current sites, they have not 
developed expansion criteria. Also, their evaluation plans do not have 
some key elements, including an approach for measuring pilot 
performance against the current process. 

Recommendation, by type and number: Seamless transition to veteran 
status: 3.5: VA and DOD should expand their collaboration in order to 
identify, collect, and maintain the specific data needed by both 
departments to recognize, treat, and prevent illness and injury 
resulting from occupational exposures and hazards experienced while 
serving in the Armed Forces; and to conduct epidemiological studies to 
understand the consequences of such events; 
Status: Fully Implemented; 
Action taken: DOD collects pre-and post-deployment health assessments 
from each servicemember on overall physical and mental health, 
injuries, and possible environmental or occupational exposures. DOD 
routinely shares this information with VA for the diagnosis and care of 
Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) 
servicemembers. DOD also collects and monitors air, soil, and water 
samples where troops are deployed. These and other shared information 
are used for cooperative medical care and research efforts. DOD has 
made progress in improving collection and reporting of health 
information as part of its health quality assurance program, including 
standardizing, documenting, and auditing its efforts; (See action taken 
on recommendation 3.7 for information on epidemiological studies.); 
Action remaining: None. 

Recommendation, by type and number: Seamless transition to veteran 
status: 3.6: By fiscal year 2004, VA and DOD should initiate a process 
for routine sharing of each servicemember's assignment history, 
location, occupational exposure, and injuries information; 
Status: Fully Implemented; 
Action taken: Since 2005, DOD has sent VA monthly electronic health 
assessment and assignment information on deactivated or separated 
servicemembers. The assessment data include assignment history, 
location, occupational exposure, and injuries. In addition, DOD 
routinely sends VA data on servicemembers deployed to OEF/OIF and on 
those who have entered DOD's physical evaluation process, which is used 
to determine disability status. The Information Management/Information 
Technology Working Group of the HEC continues efforts to improve 
medical data sharing; 
Action remaining: None. 

Recommendation, by type and number: Seamless transition to veteran 
status: 3.7: The department should: (1) add an ex officio member from 
VA to the Armed Forces Epidemiological Board and to the DOD Safety and 
Occupational Health Committee; (2) implement continuous health 
surveillance and research programs to identify the long-term health 
consequences of military service in high-risk occupations, settings, or 
events; and (3) jointly issue an annual report on force health 
protection, and make it available to the public; 
Status: Fully Implemented; 
Action taken: An ex officio member from VA was added to the Defense 
Health Board (formerly the Armed Forces Epidemiological Board) and the 
DOD Safety and Occupational Health Committee; VA and DOD conduct health 
surveillance and research using data collected on high-risk 
occupations, settings, and events through pre-and post-deployment 
health assessments. Data collected by DOD are also used to monitor air, 
soil, and water samples from each deployment location for health 
surveillance and research. VA and DOD, along with HHS, funded medical 
surveillance initiatives and long-term research projects related to 
OIF/OEF deployment and illnesses in veterans of the 1991 Gulf War. For 
example, VA and DOD collaborated on epidemiological projects related to 
exposure to depleted uranium and chemical warfare agents. VA and DOD 
also developed an inventory of 432 medical research projects on the 
health of deployed servicemembers and veterans that is updated 
annually; VA and DOD officials told us that the Deployment Health 
section of the JEC annual report, available online, serves as the force 
health protection report; 
Action remaining: None. 

Recommendation, by type and number: Removing barriers to collaboration: 
4.1: The Secretaries of Veterans Affairs and Defense should revise 
their health care organizational structures in order to provide more 
effective and coordinated management of their individual health care 
systems, enhance overall health care outcomes, and improve the 
structural congruence between the two departments; 
Status: Partially Implemented; 
Action taken: VA and DOD officials told us that the JEC and the SOC 
provide more effective and coordinated management of the departments' 
individual health care systems and that they do not believe revising 
health care organizational structures would necessarily improve 
coordination. The SOC was established in 2007 to bring high-level 
attention to addressing problems with the care and services for 
servicemembers returning from OEF/OIF.[J] According to VA and DOD 
officials, the SOC is expected to disband by the end of 2008 or early 
2009, and responsibilities for VA and DOD collaboration will shift to 
the JEC; 
Action remaining: VA and DOD have not revised their health care 
organizational structures to improve structural congruence between the 
two departments. The departments are relying on the JEC and the SOC to 
coordinate efforts between their individual health care systems. 

Recommendation, by type and number: Removing barriers to collaboration: 
4.2: The Secretaries of Veterans Affairs and Defense, based on the 
recommendations of the interagency leadership committee, should provide 
significantly enhanced authority, accountability, and incentives to 
health care managers at the local and regional levels in order to 
enhance standardized and collaborative activities that improve health 
care delivery and control costs; 
Status: Partially Implemented; 
Action taken: The departments provided leadership and authority for 
local and regional health care managers to enhance collaboration, 
improve health care delivery, and control costs. VA states that it has 
provided accountability and incentives for local and regional managers 
through performance plans and appraisals and scoring factors for shared 
capital investment projects. DOD states that it has also eliminated 
some financial disincentives for collaboration for local MTF managers. 
In addition, the departments had 504 direct sharing agreements covering 
2,090 unique services in fiscal year 2006; The departments have also 
implemented the ongoing DOD-VA Health Care Sharing Joint Incentive Fund 
(JIF), to identify, provide incentives to, implement, fund, and 
evaluate creative coordination and sharing initiatives at the facility, 
regional, and national levels.[K] Federal law requires that VA and DOD 
each contribute a minimum of $15 million ($30 million total) into this 
fund annually. With these funds, VA and DOD had approved and funded 47 
projects as of February 2007. In addition, 7 demonstration projects 
were implemented to evaluate the success of joint projects and share 
lessons learned with other sites; 
Action remaining: VA and DOD have not demonstrated how they have 
provided either accountability or system-wide incentives for local and 
regional health care managers in support of collaboration, as 
recommended by the task force. 

Recommendation, by type and number: Removing barriers to collaboration: 
4.3: VA and DOD should integrate clinical pharmacy initiatives through 
the coordinated development of: (1) a national joint core formulary; 
and (2) a single, common clinical data screening tool by fiscal year 
2005 that ensures reliable, electronic access to complete 
pharmaceutical profiles for VA/DOD dual users across both systems; 
Status: Partially Implemented; 
Action taken: VA and DOD do not accept that a national joint core 
formulary is needed. As an alternative, they had awarded 77 joint 
national contracts for medications as of the first three quarters of 
fiscal year 2007 and continue to evaluate 24 additional drugs for joint 
contracts; VA and DOD's CHDR allows real-time bidirectional exchange of 
electronic pharmacy and drug allergy data for shared patients at seven 
sites. This enables them to share a common pharmaceutical clinical data 
screening tool, including computable data that allow both departments' 
systems to screen for potential drug interactions and allergies. VA and 
DOD officials plan to have CHDR available at all sites by summer 2008; 
The Pharmacy Re-engineering Project is under development and a joint 
team is working to improve the percentage of pharmacy data that can be 
exchanged for shared patients. Both departments have adopted a standard 
for exchanging medication-allergy data; 
Action remaining: The DOD Uniform Formulary, created under regulations 
issued pursuant to the DOD pharmacy statute,[L] prevents DOD from 
participating in a joint formulary with VA, as recommended by the task 
force. As an alternative, the departments will continue to collaborate 
on formulary decisions and expand joint pharmaceutical purchases; The 
departments have not yet fully implemented a clinical data screening 
tool and electronic pharmaceutical profiles for all shared patients, as 
recommended by the task force. To do so, VA and DOD are continuing 
their efforts to expand CHDR to all sites.[M]. 

Recommendation, by type and number: Removing barriers to collaboration: 
4.4: VA and DOD should collaborate on policy and program changes, 
through local sharing arrangements, which would permit prescriptions 
written by either VA or MTF providers to be filled for dual users by 
the other department's pharmacies; Status: Partially Implemented; 
Action taken: According to the departments, DOD is able to fill 
prescriptions from any physician, including VA providers, for all 
shared patients at MTFs, retail network pharmacies, or TRICARE mail- 
order pharmacy programs. VA will fill prescriptions for shared patients 
who are using VA providers, and may fill prescriptions written by non- 
VA providers in rare circumstances. In some locations, VA and DOD have 
local sharing agreements allowing prescriptions for shared patients to 
be filled at VA pharmacies; 
Action remaining: VA does not always fill prescriptions for shared 
patients, as recommended by the task force, because its regulations do 
not permit VA to do so.[N]. 

Recommendation, by type and number: Removing barriers to collaboration: 
4.5: VA and DOD should work with industry to establish a uniform 
methodology for medical supplies and equipment identification and 
standardization and to facilitate additional joint contracting 
initiatives. VA and DOD should identify opportunities for joint 
acquisitions in all areas of products and services; 
Status: Partially Implemented; 
Action taken: VA and DOD have worked with industry to standardize 
identification data for medical supplies and equipment through the HEC, 
and according to DOD, the departments will continue to work with 
industry and follow industry recommendations. For example, initial 
results released in September 2007 for a health care industry pilot 
demonstrated that the Global Data Synchronization Network (GDSN) has 
the potential to work for the health care industry, and industry 
leaders have recommended the GDSN as an industry-wide information 
sharing solution. In addition, according to VA, the departments have 
developed their own joint Medical/Surgical Product Data Bank as part of 
their JIF-funded joint data synchronization project. Also through the 
HEC, VA and DOD have rechartered the Acquisition and Medical Material 
Working Group to identify more ways to collaboratively acquire health 
care commodities and services; 
Action remaining: VA and DOD have not fully established a uniform 
methodology for medical supplies and equipment identification and 
standardization, as recommended by the task force. Their continued work 
with industry could facilitate their efforts on this recommendation; In 
addition, VA and DOD have not demonstrated that they have identified 
opportunities for joint acquisitions in all areas of products and 
services, as recommended by the task force, though the rechartered 
working group may have the potential to do so. 

Recommendation, by type and number: Removing barriers to collaboration: 
4.6: The interagency leadership committee should identify those 
functional areas where the departments have similar information 
requirements so that they can work together to reengineer business 
processes and information technology in order to enhance 
interoperability and efficiency; 
Status: Fully Implemented; Action taken: VA and DOD have identified 
functional areas and included them in the JSP. For example, the fiscal 
year 2004 JSP states as part of Goal 2 that VA and DOD will collaborate 
on internal and external reporting systems for patient safety. Goals 3, 
4, and 5 of the fiscal year 2004 JSP present information about goals 
directed to the seamless coordination of benefits, integrated 
information sharing, and efficiency of operations, respectively. 
Functions identified within these goals include health information 
technology; health clinical data sharing, such as in- patient 
assessments; imaging; laboratory data sharing; and delivery of 
benefits; 
Action remaining: None. 

Recommendation, by type and number: Removing barriers to collaboration: 
4.7: VA and DOD should implement facility lifecycle management 
practices on an enterprise-wide basis. This should be accomplished by 
aligning business rules, eliminating statutory barriers, and adopting 
best practices; 
Status: Partially Implemented; 
Action taken: In 2003, the JEC established the VA-DOD Construction 
Planning Committee (CPC) that provides a formalized structure to 
facilitate collaboration and coordination in achieving an integrated 
approach to capital coordination that considers both short-term and 
long-term strategic capital issues. The CPC was charged with providing 
oversight to ensure that collaborative opportunities for joint capital 
asset planning are maximized, and provides the final review and 
approval of all joint capital asset initiatives recommended by any 
element of the JEC structure. Under the CPC framework, collaborative 
efforts have been initiated for aligning business rules, eliminating 
statutory barriers, and identifying best practices for VA and DOD; For 
example, according to VA and DOD, the two departments have begun to 
share planning documents for major construction projects to determine 
those with collaborative potential and explore methods to ensure high 
potential projects are fully considered and included in both 
departments' capital investment processes. In addition, DOD adopted 
VA's capital investment methodology and adapted its analytical process 
for evaluating, prioritizing, and ranking major construction projects. 
VA, in turn, adopted DOD's facilities sustainment model to standardize 
the process for estimating funding levels for sustaining its capital 
assets portfolio. VA and DOD now use the same planning platform to 
develop projects, thus making future collaborative opportunities easier 
to define requirements; 
Action remaining: VA and DOD have not demonstrated that they have 
implemented facility lifecycle management practices on an enterprise-
wide basis, as recommended by the task force. 

Recommendation, by type and number: Removing barriers to collaboration: 
4.8: VA and DOD should declare that joint ventures are integral to the 
standard operations of both departments. Through the interagency 
leadership committee, the departments should articulate policy 
requiring that: (1) all major initiatives of each department be 
designed and tested for effectiveness and suitability in joint venture 
sites; (2) lessons learned from successful joint ventures be shared 
with other joint venture sites and also throughout the health care 
delivery systems of the two departments; and (3) all proposed VA and 
DOD facility construction within a geographic area be evaluated as a 
potential joint venture; 
Status: Partially Implemented; 
Action taken: In 2005, DOD issued a policy directive that assigned 
responsibilities and prescribed procedures for the development and 
operation of DOD-VA health care resource sharing agreements. The 
directive also defined joint ventures and discussed departmental policy 
on joint ventures, among other things; In 2005, 2006, and 2007, VA and 
DOD sponsored annual conferences to bring together leadership from all 
joint venture sites to share lessons learned; In 2006, VA established a 
Joint Venture Proposals Working Group to develop criteria for 
evaluating joint venture proposals at the department level and a 
communications strategy for use during joint venture negotiations. VA 
issued the criteria and communications strategy in a handbook in 
November 2007. The handbook details departmental policy on joint 
ventures, defines joint ventures, and identifies the process for 
reviewing and approving joint venture proposals, among other things; VA 
and DOD have also established a Joint Market Opportunities Work Group 
to examine the existing VA-DOD joint ventures and the potential for 
additional joint ventures. In the first phase of its review, the 
working group studied all eight existing VA-DOD joint venture sites to 
identify best practices, lessons learned, and challenges. The working 
group reported the findings from the first phase of its review to the 
JEC in January 2008. In the second phase of its review, the working 
group plans to assess potential opportunities for colocation and 
comanagement of VA-DOD facilities. The working group has identified 
some locations to study and expects to report its findings from the 
second phase to the JEC in July 2008; 
Action remaining: VA and DOD have not fully developed and implemented 
joint policies that state that joint ventures are integral to the 
standard operations of both departments or ensure that all major 
initiatives of each department are designed and tested for the 
effectiveness and suitability in joint venture sites, as recommended by 
the task force. 

Recommendation, by type and number: Removing barriers to collaboration: 
4.9: VA and DOD should work together to identify and address staffing 
shortfalls, develop consistent clinical scopes of practice for 
nonphysician providers, and ensure that their provider credentialing 
systems interface with each other; 
Status: Unable to determine; 
Action taken: VA and DOD piloted a credentialing interface that was 
shown to be technically feasible, but both departments told us that the 
time and money required to support and maintain a mutual electronic 
credentialing system was not warranted as the number of credentialed 
providers working in both VA and DOD facilities is too small to justify 
the expenditure. The interface is no longer in use, but according to 
VA, it may be reestablished if it is needed in the future; 
Action remaining: We are unable to determine what remains to be done to 
fully implement this recommendation, because VA and DOD have not 
provided sufficient information to determine the status of their 
progress on addressing staffing shortfalls or on developing consistent 
clinical scopes of practice for nonphysician providers. 

Source: GAO analysis of VA and DOD information and President's task 
force report. 

[A] In accordance with the Bob Stump National Defense Authorization Act 
for Fiscal Year 2003, Pub. L. No. 107-314,  712(a), 116 Stat. 2590. 
The JEC was originally called the DOD-VA Health Executive Committee. 

[B] Pub. L. No. 108-136,  583, 117 Stat. 1392, 1490 (2003) (codified 
as amended at 38 U.S.C.  320). 

[C] The six strategic goals in the JSP are related to leadership, 
commitment, and accountability; high-quality health care; seamless 
coordination of benefits; integrated information sharing; efficiency of 
operations; and joint medical contingency/readiness capabilities. 

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

[E] See GAO, Information Technology: VA and DOD Continue to Expand 
Sharing of Medical Information, but Still Lack Comprehensive Electronic 
Medical Records, GAO-08-207T (Washington, D.C.: Oct. 24, 2007). 

[F] The HIPAA Privacy Rule permits the exchange of health care 
information between VA-and DOD-covered entities for a number of 
purposes, including to provide medical treatment, to make payments for 
health care, and to make VA benefit determinations upon servicemembers' 
discharge or separation from the armed forces. See 45 C.F.R.  
164.506, 164.512(k) (2007). 

[G] See GAO, VA and DOD Health Care: Efforts to Coordinate a Single 
Physical Exam Process for Servicemembers Leaving the Military, GAO-05- 
64 (Washington, D.C.: Nov. 12, 2004). 

[H] NDAA for Fiscal Year 2008, Pub. L. No. 110-181,  1614, 122 Stat. 
3, 443-46. 

[I] See GAO, DOD and VA: Preliminary Observations on Efforts to Improve 
Care Management and Disability Evaluations for Servicemembers, GAO-08- 
514T (Washington, D.C.: Feb. 27, 2008). 

[J] To conduct its work, the SOC established work groups that focused 
on specific areas, including case management; disability evaluation 
systems; traumatic brain injury; psychological health, including post- 
traumatic stress disorder; and data sharing between VA and DOD. 

[K] In accordance with the Bob Stump National Defense Authorization Act 
for Fiscal Year 2003, Pub. L. No. 107-314,  721, 116 Stat. 2458, 2589- 
2595 (2002) (codified as amended at 38 U.S.C.  8111). 

[L] 10 U.S.C.  1074g. 

[M] See GAO, DOD and VA Outpatient Pharmacy Data: Computable Data Are 
Exchanged for Some Shared Patients, but Additional Steps Could 
Facilitate Exchanging These Data for All Shared Patients, GAO-07-554R 
(Washington, D.C.: Apr. 30, 2007). 

[N] 38 C.F.R.  17.96. 

[End of table] 

[End of section] 

Enclosure II: Comments from the Department of Veterans Affairs: 

The Secretary Of Veterans Affairs: 
Washington: 

April 14, 2008: 

Mr. Randall B. Williamson: 
Acting Director, Health Care: 
U. S. Government Accountability Office: 
441 G Street, NW: 
Washington, DC 20548: 

Dear Mr. Williamson: 

The Department of Veterans Affairs (VA) has reviewed the Government 
Accountability Office's draft report, "VA AND DOD HEALTH CARE: Progress 
Made on Implementation of 2003 President's Task Force Recommendations 
on Collaboration and Coordination, but More Remains to Be Done (GAO-08-
495R)." 

The report provides specific recommendations in areas where VA is 
continuing to work with the Department of Defense (DoD) to develop new 
strategies to assist in improving coordination and sharing between VA 
and DoD and improving health care, services and benefits for 
servicemembers and veterans. 

VA agrees with your findings and provides updated detailed information 
in the enclosure. 

Sincerely yours, 

Signed by: 

James B. Peake, M.D.: 

Enclosure: 

[End of section] 

Enclosure III: Comments from the Department of Defense: 

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

Health Affairs: 

April 11, 2008: 

Randall B Williamson: 
Acting Director, Health Care: 
U.S. Government Accountability Office: 
441 G Street, N.W.: 
Washington, DC 20548 

Dear Mr. Williamson: 

This is the Department of Defense (DoD) response to the GAO draft 
report, "VA DoD Health Care: Progress Made on Implementation of 2003 
President's Task Force Recommendations on Collaboration, But More 
Remains to Be Done," dated March 26, 2008 (GAO Code 290646/GAO-08-
495R)." The draft report examines very important aspects of our joint 
efforts to implement the numerous recommendations for improving the way 
the Departments of Defense and Veterans Affairs collaborate to deliver 
health care services to our Nation's veterans. 

I concur with the draft report's findings and conclusion provided that 
the attached technical comments are incorporated into the final report. 
DoD was and continues to be highly appreciative of the myriad 
recommendations to improve the manner in which we work with the 
Department of Veterans Affairs to provide benefits and services to the 
brave men and women and their families who serve our country. 

Again, thank you for the opportunity to provide these comments. My 
points of contact for additional information are Mr. Ken Cox 
(Functional) at (703) 681-4299 and Mr. Gunther Zimmerman (Audit 
Liaison) at (703) 681-3492. 

Sincerely, 

Signed by: 

S. Ward Casscells, MD:  

Enclosure: 
As stated: 

[End of section] 

Enclosure IV: 

GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Randall Williamson, (206) 287-4860 or williamsonr@gao.gov: 

Acknowledgments: 

In addition to the contact named above, James C. Musselwhite, Jr., 
Assistant Director; Kye Briesath; Vashun Cole; Julie L. Thomas; Timothy 
Walker; Greg Whitney; and Robert L. Williams, Jr. made major 
contributions to this report. 

[End of section] 

Related GAO Products: 

VA Health Care: Additional Efforts to Better Assess Joint Ventures 
Needed. GAO-08-399. Washington, D.C.: March 28, 2008. 

DOD and VA: Preliminary Observations on Efforts to Improve Care 
Management and Disability Evaluations for Servicemembers. GAO-08-514T. 
Washington, D.C.: February 27, 2008. 

Information Technology: VA and DOD Continue to Expand Sharing of 
Medical Information, but Still Lack Comprehensive Electronic Medical 
Records. GAO-08-207T. Washington, D.C.: October 24, 2007. 

DOD and VA: Preliminary Observations on Efforts to Improve Health Care 
and Disability Evaluations for Returning Servicemembers. GAO-07-1256T. 
Washington, D.C.: September 26, 2007. 

GAO Findings and Recommendations Regarding DOD and VA Disability 
Systems. GAO-07-906R. Washington, D.C.: May 25, 2007. 

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

DOD and VA Outpatient Pharmacy Data: Computable Data Are Exchanged for 
Some Shared Patients, but Additional Steps Could Facilitate Exchanging 
These Data for All Shared Patients. GAO-07-554R. Washington, D.C.: 
April 30, 2007. 

VA and DOD Health Care: Opportunities to Maximize Resource Sharing 
Remain. GAO-06-315. Washington, D.C.: March 20, 2006. 

Results-Oriented Government: Practices That Can Help Enhance and 
Sustain Collaboration among Federal Agencies. GAO-06-15. Washington, 
D.C.: October 21, 2005. 

Defense Health Care: Improvements Needed in Occupational and 
Environmental Health Surveillance during Deployments to Address 
Immediate and Long-term Health Issues. GAO-05-632. Washington, D.C.: 
July 14, 2005. 

VA and DOD Health Care: Efforts to Coordinate a Single Physical Exam 
Process for Servicemembers Leaving the Military. GAO-05-64. Washington, 
D.C.: November 12, 2004. 

Department of Veterans Affairs: Federal Gulf War Illnesses Research 
Strategy Needs Reassessment. GAO-04-767. Washington, D.C.: June 1, 
2004. 

[End of section] 

Footnotes: 

[1] Pub. L. No. 97-174, 96 Stat. 70 (1982); Senate Report 97-137. 
Before the Sharing Act was passed in 1982, VA and DOD health care 
facilities--many of which were in close or joint locations--operated 
virtually independently of each other. 

[2] See the Bob Stump National Defense Authorization Act for Fiscal 
Year 2003 under which VA and DOD were required to develop a joint 
strategic plan and incorporate the joint goals and strategies into each 
department's strategic and performance plans. Pub. L. No. 107-314,  
721, 116 Stat. 2458, 2589-2595 (2002) (codified as amended at 38 U.S.C. 
 8111). 

[3] See Related GAO Products at the end of this report. 

[4] Exec. Order No. 13,214, 66 Fed. Reg. 29,447 (May 31, 2001). 

[5] President's Task Force to Improve Health Care Delivery for Our 
Nation's Veterans (May 26, 2003). 

[6] Task Force on Returning Global War on Terror Heroes (Washington, 
D.C.: Apr. 19, 2007). 

[7] Serve, Support, Simplify: Report of the President's Commission on 
Care for America's Returning Wounded Warriors (July 30, 2007). 

[8] Honoring the Call to Duty: Veterans' Disability Benefits in the 
21st Century, Veterans' Disability Benefits Commission (Washington, 
D.C.: Oct. 3, 2007). 

[9] The remaining chapter, "Timely Access to Health Services and the 
Mismatch between Demand and Funding," includes three recommendations 
that are not included in our scope. The recommendations in this chapter 
focus on congressional appropriations and related actions rather than 
department activities. 

[10] The JEC is co-chaired by the Deputy Secretary of Veterans Affairs 
and the Under Secretary of Defense for Personnel and Readiness, and the 
membership--which is selected by the co-chairs--consists of senior 
executives from both VA and DOD. 

[11] The Privacy Rule applies to covered entities and specifies how 
individually identifiable health data may be used and disclosed by 
covered entities. See 45 C.F.R.  164.500(a), et seq. (2007). Covered 
entities are defined in the Privacy Rule as health plans, 
clearinghouses, and certain health care providers. Both the DOD and VA 
health care systems are covered entities. See 45 C.F.R.  160.103 
(2007). All covered entities had to comply with the Privacy Rule by 
April 14, 2003, with the exception of small health plans. 

[12] The HIPAA Privacy Rule permits the exchange of health care 
information between VA-and DOD-covered entities for a number of 
purposes, including to provide medical treatment, to make payments for 
health care, and to make VA benefit determinations upon servicemembers' 
discharge or separation from the armed forces. See 45 C.F.R.  
164.506, 164.512(k) (2007). 

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