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Testimony:

Before the Subcommittee on Oversight and Investigations, Committee on 
Veterans' Affairs, House of Representatives:

United States General Accounting Office:

GAO:

For Release on Delivery Expected at 10:30 a.m. EST:

Wednesday, November 19, 2003:

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:

Statement of Linda D. Koontz, Director Information Management Issues:

GAO-04-271T:

GAO Highlights:

Highlights of GAO-04-271T, a report to the Subcommittee on Oversight 
and Investigations, House Committee on Veterans' Affairs 

Why GAO Did This Study:

For the past 5 years, the Departments of Veterans Affairs and Defense 
have been working to exchange health care data and create electronic 
records for veterans and active duty personnel. Such exchange is seen 
as a means of reducing the billions of dollars that the departments 
spend annually on health care services and making such data more 
readily accessible to those treating our countryís approximately 13 
million veterans, military personnel, and dependents. This is 
especially critical when military personnel are engaged in conflicts 
all over the world, and their health records can reside at multiple 
locations. 

GAO has reported on these efforts several times, most recently in 
September 2002. At the request of the Subcommittee, GAO is updating 
its observations on the departmentsí efforts, focusing on (1) the 
reported status of the ongoing, one-way exchange of data, the Federal 
Health Information Exchange, and (2) progress toward achieving the 
longer term two-way exchange under the HealthePeople (Federal) 
initiative. 

What GAO Found:

Access to medical data that includes information on the entire lives 
of veterans and active duty military personnel represents an enormous 
step toward enhanced and more effective medical care. VA and DOD are 
pursuing this goal in two stages. 

* Federal Health Information Exchange. This current, one-way transfer 
of health care data from DOD to VA is already allowing clinicians in 
VA medical centers to make faster, more informed decisions through 
ready access to information on almost 2 million patients, thereby 
improving their level of health care delivery. The programís fiscal 
year 2003 cost was just over $11 million.

* HealthePeople (Federal). The realization of this longer term 
strategy to enable electronic, two-way information sharing is farther 
out on the horizon. The departments are proceeding with projects that 
are expected to result in a limited two-way exchange of health data by 
the end of 2005. However, VA and DOD face significant challenges in 
implementing a full data exchange capability. Although a high-level 
strategy exists, the departments have not yet clearly articulated a 
common health information infrastructure and architecture to show how 
they intend to achieve the data exchange capability or what they will 
be able to exchange by the end of 2005. In addition, critical to 
achieving the two-way exchange will be completing the standardization 
of the clinical data that these departments plan to share. Without 
standardization, the task of sharing meaningful data could be more 
complex and may not prove successful.

www.gao.gov/cgi-bin/getrpt?GAO-04-271T.

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

[End of section]

Mr. Chairman and Members of the Subcommittee:

Thank you for inviting us to testify on actions of the Department of 
Veterans Affairs (VA) and the Department of Defense (DOD) to achieve 
the ability to exchange patient health care data and create an 
electronic record for veterans and active duty personnel. VA and DOD, 
collectively, provided health care services to approximately 13 million 
veterans, military personnel, and dependents at a cost of about $47 
billion in fiscal year 2002. While in military status and later as 
veterans, many patients tend to be highly mobile and, consequently, 
their health records may be at multiple federal and nonfederal medical 
facilities, both in and outside of the United States. Thus, having 
readily accessible data on active duty personnel and veterans is 
important to facilitate providing quality health care to them.

VA and DOD have been pursuing ways to share data in their health 
information systems and create electronic records since 1998, their 
actions following the President's call for the development of an 
interface to allow the two departments to share patient health 
information.[Footnote 1] Since undertaking this mission, however, the 
departments have faced considerable challenges, leading to repeated 
changes in the focus of their initiative and the target dates for its 
accomplishment. Our prior reports supporting the initiative[Footnote 2] 
noted disappointing progress, exacerbated in large part by inadequate 
accountability and poor planning and oversight, which raised doubts 
about the departments' ability to achieve an electronic interface among 
their health information systems. When we last reported on the 
initiative in September 2002,[Footnote 3] VA and DOD had taken some 
actions aimed at strengthening their joint efforts. For example, they 
had clarified key roles and responsibilities for the initiative and 
begun executing revised near-and long-term strategies for achieving the 
electronic information exchange capability.

My statement today will discuss our observations regarding VA's and 
DOD's continued actions over the past year to further their 
implementation of the electronic information exchange, including an 
update on (1) the status and reported benefits of the ongoing near-term 
initiative, the Federal Health Information Exchange (FHIE), and (2) the 
departments' progress and challenges in achieving the longer term, two-
way exchange of data under the HealthePeople (Federal) initiative.

In conducting this work, we obtained and reviewed relevant 
documentation and interviewed key agency officials regarding VA's 
decisions and actions, in conjunction with DOD, to develop an 
electronic medical record for exchanging patient information. We 
analyzed the departments' plans and strategies for the HealthePeople 
(Federal) initiative and data on patient information that is currently 
being transmitted by DOD to VA. In addition, to observe data retrieval 
capabilities of the Federal Health Information Exchange, we conducted a 
site visit at the VA medical center in Washington, D.C. We performed 
our work in accordance with generally accepted government auditing 
standards, from March through November 2003.

Results in Brief:

The current one-way transfer of health information resulting from the 
departments' near-term solution--the Federal Health Information 
Exchange--represents a positive undertaking that has begun enabling 
information sharing between DOD and VA. As part of the initiative, 
electronic health data from separated (retired or discharged) service 
members contained in DOD's Military Health System Composite Health Care 
System are being transmitted monthly to a VA FHIE repository,[Footnote 
4] which VA clinicians access through the department's current health 
system, the Veterans Health Information Systems and Technology 
Architecture. As a result, VA clinicians now have more readily 
accessible DOD health data, such as laboratory, pharmacy, and radiology 
records, on almost 2 million patients and have noted the benefits of 
this current capability in improving health care delivery. Further, 
although not originally included in the FHIE plan, VA officials have 
stated that efforts are underway to provide access to outpatient and 
retail pharmacy data.

Realizing the departments' longer term strategy--HealthePeople 
(Federal)--is farther out on the horizon. VA officials have stated that 
the departments are on schedule to provide a limited capability for an 
electronic, two-way exchange of patient health information by the end 
of 2005. However, VA and DOD face significant challenges in 
implementing a full data exchange capability. Although a high-level 
strategy exists, the departments have not yet clearly articulated a 
common health information infrastructure and architecture to show how 
they intend to achieve the data exchange capability or what exactly 
they will be able to exchange by the end of 2005. In addition, critical 
to achieving the two-way exchange will be completing the 
standardization of the clinical data that these departments plan to 
share. Without standardization, the task of sharing meaningful data is 
made more complex, and may not prove successful. Until these essential 
issues are resolved, the departments cannot be assured that the 
HealthePeople (Federal) initiative will deliver expected benefits 
within established time frames.

Background:

In 1998, VA and DOD, along with the Indian Health Service (IHS), began 
the Government Computer-Based Patient Record (GCPR) project--an 
initiative to share patient health care data. At that time, each agency 
collected and maintained patient health information in separate 
systems, and their health facilities could not electronically share 
patient health information across agency lines. GCPR was envisioned as 
an electronic interface that would allow physicians and other 
authorized users at VA, DOD, and IHS health facilities to access data 
from any of the other agencies' health facilities. The interface was 
expected to compile requested patient information in a "virtual" record 
that could be displayed on a user's computer screen.

In reporting on the initiative in April 2001,[Footnote 5] we raised 
doubts about GCPR's ability to provide expected benefits. We noted that 
the project was experiencing schedule and cost overruns and was 
operating without clear goals, objectives, and consistent leadership. 
We recommended that the participating agencies (1) designate a lead 
entity with final decision-making authority and establish a clear line 
of authority for the GCPR project, and (2) create comprehensive and 
coordinated plans that included an agreed-upon mission and clear goals, 
objectives, and performance measures, to ensure that the agencies could 
share comprehensive, meaningful, accurate, and secure patient health 
care data. VA, DOD, and IHS agreed with our findings and 
recommendations.

In March 2002, however, we again reported that the project was 
continuing to operate without clear lines of authority or a lead entity 
responsible for final decision-making.[Footnote 6] Further, the project 
continued to move forward without comprehensive and coordinated plans, 
including an agreed-upon mission and clear goals, objectives, and 
performance measures. In addition, the participating agencies had 
announced a revised strategy that was considerably less encompassing 
than the project was originally intended to be. For example, rather 
than serve as an interface to allow data sharing across the three 
agencies' disparate systems, as originally envisioned, the revised 
strategy initially called only for a one-way transfer of data from 
DOD's current health care information system to a separate database 
that VA hospitals could access. In further reporting on this initiative 
in June 2002, we recommended that VA, DOD, and IHS revise the original 
goals and objectives of the project to align with their current 
strategy, commit the executive support necessary to adequately manage 
the project, and ensure that it followed sound project management 
principles.[Footnote 7]

When we last testified on the initiative in September 2002,[Footnote 8] 
VA had reported some progress toward achieving shared patient health 
care data and the two departments had formally revised both the name 
and the strategy for the initiative. Specifically, the two departments 
had renamed the project the Federal Health Information Exchange (FHIE) 
Program. In addition, consistent with our prior recommendation, they 
had finalized a memorandum of agreement designating VA as the lead 
entity in implementing FHIE.

With this agreement, FHIE became a joint effort between VA and DOD to 
achieve the exchange of health care information in two phases. The 
first phase, completed in mid-July 2002, enabled the one-way transfer 
of data from DOD's existing health care information system to a 
separate database that VA hospitals could access.

Further, the revised strategy envisioned VA and DOD pursuing a longer 
term, two-way exchange of clinical information.[Footnote 9] This 
initiative, known as HealthePeople (Federal), is premised upon the 
departments' development of a common health information infrastructure 
and architecture comprising standardized data, communications, 
security, and high-performance health information systems. The 
departments developed the strategy for achieving the two-way exchange 
in September 2002 and anticipated achieving a limited capability by the 
end of 2005.

VA AND DOD Continue to Report Success in Implementing the Feeral Health 
Information Exchange Near-Term Solution:

Over the past year, VA and DOD have continued to realize success in the 
implementation and use of FHIE. In achieving the exchange of health 
care information, electronic data from separated (retired or 
discharged) service members contained in DOD's Military Health System 
Composite Health Care System (CHCS) are being transmitted monthly to a 
VA FHIE repository, which VA clinicians access through the Computerized 
Patient Record System (CPRS) in the Veterans Health Information Systems 
and Technology Architecture (VistA), VA's current health care system. 
This information exchange capability is currently available to all VA 
medical centers and has given VA clinicians the ability to access and 
display the data through CPRS remote data views[Footnote 10] about 6 
weeks after the service member's separation. VA and DOD reported 
spending about $11 million in fiscal year 2003 to cover completion and 
maintenance of FHIE.

According to program officials, FHIE is showing positive results by 
providing a wide range of health care information to enable clinicians 
to make faster and more informed decisions regarding the care of 
veterans. The officials stated that the repository presently contains 
data on almost 2 million patients. This includes clinical data on 
almost 1.8 million personnel who separated from the military between 
1987 and June 2003. The data consist of over 23 million laboratory 
records, 24 million pharmacy records, and over 4 million radiology 
records. A second phase of the FHIE initiative, completed in September 
2003, added to the base of health information available to VA 
clinicians by including discharge summaries;[Footnote 11] allergy 
information; admissions, disposition, and transfer information; and 
consultation results. A clinician at VA's Washington, D.C. medical 
center noted that the information provided through FHIE has proved 
particularly valuable for treating emergency-room and first-time 
patients by providing ready access to information on patients' existing 
medical conditions and current drug prescriptions.

The program manager added that FHIE is providing ready access to health 
information. It is currently capable of accommodating up to 800 queries 
per hour, with an average response rate of 4 seconds per query. For the 
month of September 2003, VA clinicians made over 1,900 authorized 
queries to the database. Further, as we observed during an FHIE 
demonstration at the medical center, the capability has resulted in an 
almost instantaneous display of DOD patient data in the same format as 
other data residing in CPRS, thus facilitating its use.

Although nearing completion, VA officials indicated, additional patient 
information from DOD will be added to the FHIE database. For example, 
they stated that efforts are currently under way to add, by the end of 
December, outpatient pharmacy data (such as mail order and retail 
pharmacy profiles) that are housed in DOD's Pharmacy Data Transaction 
Service, and by the end of February 2004, other outpatient records.

Actions Toward a Common Health Information Infrastructure Are 
Progressing, but Significant Challenges Remain:

Beyond FHIE, VA and DOD are proceeding with a joint, long-term strategy 
involving the two-way exchange of clinical information. Under this 
strategy, VA and DOD plan to seek opportunities for sharing existing 
systems and technology and explore the convergence of VA and DOD health 
information applications consistent with mission requirements. 
According to the Veterans Health Administration's Acting Deputy Chief 
Information Officer (CIO) for Health, and the Military Health System's 
CIO, this joint VA/DOD initiative is expected to allow the secured 
sharing of health data required by their health care providers between 
systems that each is currently developing--DOD's Composite Health Care 
System II (CHCS II) and VA's HealtheVet VistA. Critical to achieving 
this capability is an interface to allow the exchange of patient health 
information between each system's data repository.

Under the HealthePeople (Federal) strategy, upon entering military 
service, a health record for the service member will be created and 
stored in DOD's CHCS II clinical data repository. The record will 
remain in the clinical data repository and be updated as the service 
member receives medical care. When the individual separates from active 
duty and, if eligible, seeks medical care at a VA facility, VA will 
then create a medical record for the individual, which will be stored 
in its health data repository. Upon viewing the medical record, the VA 
clinician would be alerted and provided access to clinical information 
on the individual also residing in DOD's repository. In the same 
manner, when a veteran seeks medical care at a military treatment 
facility, the attending DOD clinician would be alerted and provided 
access to the clinical information existing in VA's repository. 
According to VA and DOD, the planned approach would make virtual 
medical records displaying all available clinical information from the 
two repositories accessible to both departments' clinicians.

VA and DOD Are Making Progress, but Full Implementation of Joint 
Strategy Is Years Away:

VA's and DOD's joint strategy for accomplishing the two-way exchange of 
health information, developed in September 2002, depends on 
successfully implementing and achieving an electronic interface between 
individual health information systems that each department is currently 
developing. These systems development efforts began as separate, 
department-specific initiatives in which VA aimed to enhance its 
existing health information system utilizing modern tools and 
languages, and DOD aimed to replace several of its health information 
systems to achieve cost efficiencies and a computer-based patient 
record. Work on modernizing VA's new system, HealtheVet (VistA), began 
in 2001, and development of DOD's new system, CHCS II, began in 1997.

Since establishing the strategy, VA and DOD have made some progress on 
systems development efforts that will support achieving health data 
exchange. Currently, VA and DOD are in different stages of completing 
their systems. As shown in table 1, VA began work on one of the key 
initiatives intended to support HealthePeople (Federal)--the health 
data repository--in June 2001; it is currently testing the design of 
this database. VA plans to complete the repository by July 2006; it 
projects completing all six initiatives comprising HealtheVet (VistA) 
over the next 9 years, with a final module on scheduling replacement 
expected in May 2012.

Table 1: HealtheVet (VistA) Initiatives:

HealtheVet Initiative: Health Data Repository (HDR); Purpose: Establish 
a repository of clinical information normally residing on one or more 
independent platforms; Initiative Start Date: June 2001; Projected 
Completion Date: 2006.

HealtheVet Initiative: Billing Replacement; Purpose: Obtain a modern, 
high-performance billing system that will support an increase to third-
party payments; Initiative Start Date: April 2002; Projected Completion 
Date: 2006.

HealtheVet Initiative: Laboratory; Purpose: Clinically oriented system 
designed to provide data to health care personnel; Initiative Start 
Date: February 2003; Projected Completion Date: 2007.

HealtheVet Initiative: Pharmacy; Purpose: Facilitate improved VA 
pharmacy operations, customer service, and patient safety, concurrent 
with the pursuit of full reengineering of VA pharmacy applications; 
Initiative Start Date: April 2002; Projected Completion Date: 2008.

HealtheVet Initiative: Imaging; Purpose: Provide complete online data 
to healthcare providers, to increase clinician productivity, facilitate 
medical decision-making, and improve quality of care; Initiative Start 
Date: October 2002; Projected Completion Date: 2011.

HealtheVet Initiative: Appointment Scheduling Replacement; Purpose: 
Provide VistA users with a redesigned scheduling capability to better 
meet the needs of VHA facility staff and patients; Initiative Start 
Date: May 2001; Projected Completion Date: 2012.

Source: VA:

[End of table]

As table 2 reflects, DOD is incrementally deploying CHCS II in five 
blocks, with each block providing additional capabilities to its 
system. The department is currently proceeding with limited deployment 
of its graphical user interface for clinical outpatient processes. In 
addition, DOD has completed its clinical data repository, and a 
department official stated that as each site implements CHCS II, data 
in CHCS will be converted to the new system. DOD expects to complete 
deployment of all of its major system capabilities by September 2008.

Table 2: CHCS II Deployment Information:

Block Number: 1 (release 1); Major Capabilities: Adds a graphical user 
interface for clinical outpatient processes; Status: Limited deployment 
underway; Projected Completion Date: September 2005.

Block Number: 2 (release 2); Major Capabilities: Support for general 
dentistry; Status: Deployment to Operation, Test & Evaluation sites 
during the 2nd Qtr of FY04; Projected Completion Date: September 2005.

Block Number: 3 (releases 3&4); Major Capabilities: Provides pharmacy, 
laboratory, radiology, and immunizations capabilities; Status: Plan 
under way to award a contract for Block 3 in 2nd Qtr FY 04 and begin 
requirements analysis by 4th Qtr FY04; Projected Completion Date: 
September 2006.

Block Number: 4 (releases 5&6); Major Capabilities: Provides inpatient 
and scheduling capabilities; Status: Begin requirements development and 
analysis in 2nd Qtr FY 04; Projected Completion Date: September 2007.

Block Number: 5 (release 7); Major Capabilities: Additional 
Capabilities as Defined; Status: Begin requirements development and 
analysis in early 1st Qtr FY05; Projected Completion Date: September 
2008.

Source: DOD.

[End of table]

Although VA and DOD officials do not expect their departments' systems 
to be fully implemented until 2012 and 2008, respectively, they 
anticipate being able to exchange some degree of clinical information 
through an interface between DOD's clinical data repository and VA's 
planned health data repository by the end of calendar year 2005. VA 
officials explained that by that time, they expect to have developed 
the HealtheVet (VistA) health data repository to a point at which it 
will have limited data. However, the departments have not yet 
articulated exactly what data will be available.

Also critical, VA and DOD have begun adopting data standards. Data 
standardization is essential to allowing the exchange of health 
information from disparate systems and improving decision-making by 
providing health information when and where it is needed. In accordance 
with the Consolidated Health Informatics Initiative,[Footnote 12] in 
March 2003, VA and DOD, along with the Department of Health and Human 
Services, announced the adoption of four standards to allow the 
transmission of messages and one standard that allows laboratory 
results to be presented uniformly in any system. In addition, VA 
officials stated that the departments have examined and concluded that 
their existing legislation and policies meet the intent of the Health 
Insurance Portability and Accountability Act.

VA and DOD Face Challenges in Moving Toward HealthePeople (Federal):

VA and DOD face key challenges to completing HealthePeople (Federal) 
that raise doubts as to when and to what extent a true virtual health 
record will be achieved. Although a high-level strategy exists, the 
HealthePeople (Federal) joint work group faces the challenge of clearly 
articulating a common health information infrastructure and 
architecture to show how they intend to achieve the data exchange 
capability, or just what they will be able to exchange by the end of 
2005. Such an architecture is necessary for ensuring that the 
departments have defined a level of detail and specificity needed to 
build the data repository interface, including interface requirements 
and design specifications. For example, having detailed specifications 
would assist VA in making critical decisions such as the manner in 
which it will store its electronic data. According to VA officials, 
they have not yet determined whether one central or several regional 
data repositories would best facilitate access to the patient 
information and achieve the timely response rates required by 
clinicians at its medical facilities.

Another critical challenge to successfully implementing HealthePeople 
(Federal) will be completing the standardization of the data elements 
of each department's health records. While standards for laboratory 
results were adopted in 2003, VA and DOD face a significant undertaking 
to standardize the remaining health data. To lend perspective to the 
enormity of this task, according to the joint strategy that VA and DOD 
have developed, VA will have to migrate over 150 variations of clinical 
and demographic data to one standard, and DOD will have to migrate over 
100 variations of clinical data to one standard. VA officials have 
indicated that as various HealtheVet (VistA) applications are 
developed, they plan to incorporate clinical data standards. Further, 
they and DOD officials maintain that their departments, along with the 
Department of Health and Human Services, are actively pursuing the 
development and adoption of such data standards. Nonetheless, they 
remain uncertain as to what degree of standardization (beyond the 
laboratory result standard that has been adopted) will be achieved by 
the 2005 milestone for implementing the two-way exchange of health 
information.

In summary, in pursuing an electronic exchange of patient health 
information, VA and DOD are taking a vital step toward facilitating 
services to our nation's active duty personnel and veterans. The 
ability to readily access medical records covering the lifecycle of 
service members and veterans would enhance the effectiveness of care to 
these individuals. In working toward this capability, VA and DOD have 
achieved a measure of success in sharing data, as evidenced by VA 
clinicians now having access to military health records for veterans 
through FHIE. However, a virtual medical record based on the two-way 
exchange of data between VA and DOD is far from being achieved. The 
departments face significant challenges in realizing this longer term 
strategy. Without having clearly articulated a common health 
information infrastructure and architecture, the departments lack the 
details and specificity essential to determining how they will achieve 
the data exchange capability.

Mr. Chairman, this concludes my statement. I would be pleased to 
respond to any questions that you or other members of the Subcommittee 
may have at this time.

Contacts and Acknowledgments:

For information regarding this testimony, please contact Linda D. 
Koontz, Director, or Valerie Melvin, Assistant Director, Information 
Management Issues, at (202) 512-6240 or at koontzl@gao.gov or 
melvinv@gao.gov, respectively. Other individuals making key 
contributions to this testimony include Barbara S. Oliver, Eric L. 
Trout, Michael P. Fruitman, and J. Michael Resser.


FOOTNOTES

[1] In 1996, the Presidential Advisory Committee on Gulf War Veterans' 
Illnesses reported on many deficiencies in VA's and DOD's data 
capabilities for handling service members' health information. In 
November 1997, the President called for the two agencies to start 
developing a "comprehensive, life-long medical record for each service 
member," and in 1998 issued a directive requiring VA and DOD to develop 
a "computer-based patient record system that will accurately and 
efficiently exchange information."

[2] U.S. General Accounting Office, Computer-Based Patient Records: 
Better Planning and Oversight by VA, DOD, and IHS [Indian Health 
Service] Would Enhance Health Data Sharing, GAO-01-459 (Washington, 
D.C.: Apr. 30, 2001); VA Information Technology: Progress Made, but 
Continued Management Attention Is Key to Achieving Results, GAO-02-369T 
(Washington, D.C.: Mar. 13, 2002); and VA Information Technology: 
Management Making Important Progress in Addressing Key Challenges 
GAO-02-1054T (Washington, D.C.: Sept. 26, 2002).

[3] GAO-02-1054T.

[4] A repository is an information system used to store and access 
data.

[5] GAO-01-459.

[6] GAO-02-369T.

[7] U.S. General Accounting Office, Veterans Affairs: Sustained 
Management Attention Is Key to Achieving Information Technology 
Results, GAO-02-703 (Washington, D.C.: June 12, 2002).

[8] GAO-02-1054T.

[9] IHS, which had been a part of the early efforts, was not included 
in FHIE, but was expected to assume a role in the longer term project-
-HealthePeople (Federal).

[10] CPRS remote data views is an application that allows authorized 
users to access patient health care data from any VA medical facility.

[11] Discharge summaries will include inpatient histories, diagnoses, 
and procedures.

[12] The Consolidated Health Informatics Initiative, created under the 
President's Management Agenda, identified a portfolio of 24 target 
areas for data and messaging standards that would enable all agencies 
in the federal health enterprise to more readily exchange clinical 
health information.