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Interoperability Are Ongoing; Program Office Management Needs 
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Report to Congressional Committees: 

United States Government Accountability Office: 
GAO: 

July 2009: 

Electronic Health Records: 

DOD and VA Efforts to Achieve Full Interoperability Are Ongoing; 
Program Office Management Needs Improvement: 

GAO-09-775: 

GAO Highlights: 

Highlights of GAO-09-775, a report to congressional committees. 

Why GAO Did This Study: 

The National Defense Authorization Act for Fiscal Year 2008 required 
the Department of Defense (DOD) and the Department of Veterans Affairs 
(VA) to accelerate their exchange of health information and to develop 
systems or capabilities that allow for interoperability (generally, the 
ability of systems to exchange data) by September 30, 2009. It also 
required compliance with federal standards and the establishment of a 
joint interagency program office to function as a single point of 
accountability for the effort. 

Further, the act directed GAO to semiannually report on the progress 
made in achieving these requirements. For this third report, GAO 
evaluated (1) the departments’ progress and plans toward sharing fully 
interoperable electronic health information that comply with federal 
standards and (2) whether the interagency program office is positioned 
to function as a single point of accountability. To do so, GAO analyzed 
agency documentation on project status and conducted interviews with 
agency officials. 

What GAO Found: 

DOD and VA have taken steps to meet six objectives that they identified 
for achieving full interoperability in compliance with applicable 
standards (see table) by September 30, 2009. Specifically, the 
departments have achieved planned capabilities for three of the 
objectives—refine social history data, share physical exam data, and 
demonstrate initial network gateway operation. For the remaining three 
objectives, the departments have partially achieved planned 
capabilities, with additional work needed to fully meet the objectives. 
Regarding the objective to expand questionnaires and self-assessment 
tools, this additional work is intended to be completed by the 
deadline. The departments’ officials have stated that they intend to 
meet the objectives to expand DOD’s inpatient medical records system 
and demonstrate initial document scanning; however, additional work 
will be required beyond September to perform all the activities 
necessary to meet clinicians’ needs for health information. 

Table: Description of DOD and VA Interoperability Objectives: 

Objective: Refine social history data; Description: DOD will begin 
sharing with VA social history data currently captured in the DOD 
electronic health record. Such data describe, for example, patients’ 
involvement in hazardous activities and tobacco and alcohol use. 

Objective: Share physical exam data; Description: DOD will provide an 
initial capability to share with VA its electronic health record 
information that supports the physical exam process when a service 
member separates from active military duty. 

Objective: Demonstrate initial network gateway operation; Description: 
DOD and VA will demonstrate the operation of secure network gateways 
that provide expanded bandwidth to support information sharing between 
DOD and VA healthcare facilities. 

Objective: Expand questionnaires and self-assessment tools; 
Description: DOD will provide all periodic health assessment data 
stored in its electronic health record to VA such that questionnaire 
responses are viewable with the questions that elicited them. 

Objective: Expand DOD inpatient medical records system; Description: 
DOD will expand its inpatient medical records system to at least one 
additional site in each military medical department (one Army, one Air 
Force, and one Navy for a total of three sites). 

Objective: Demonstrate initial document scanning; Description: DOD will 
demonstrate an initial capability for scanning service members’ medical 
documents into its electronic health record and sharing the documents 
electronically with VA. 

Source: GAO based on DOD and VA data. 

[End of table] 

The DOD/VA Interagency Program Office is not yet effectively positioned 
to function as a single point of accountability for the implementation 
of fully interoperable electronic health record systems or capabilities 
between DOD and VA. While the departments have made progress in setting 
up the office by hiring additional staff, they continue to fill key 
leadership positions on an interim basis. Further, while the office has 
begun to demonstrate responsibilities outlined in its charter, it is 
not yet fulfilling key information technology management 
responsibilities in the areas of performance measurement (as GAO 
previously recommended), project planning, and scheduling, which are 
essential to establishing the office as a single point of 
accountability for the departments’ interoperability efforts. 

What GAO Recommends: 

GAO is recommending that the departments improve management of their 
interoperability efforts by establishing a project plan and a complete 
and detailed integrated master schedule. Commenting on a draft of this 
report, DOD, VA, and the interagency program office concurred with GAO’
s recommendation. 

View [hyperlink, http://www.gao.gov/products/GAO-09-775] or key 
components. For more information, contact Valerie C. Melvin at (202) 
512-6304 or melvinv@gao.gov. 

[End of section] 

Contents: 

Letter: 

Background: 

DOD and VA Have Taken Steps to Meet their Objectives, but Activities 
Are Expected to Remain after the Deadline for Achieving Full 
Interoperability: 

DOD/VA Interagency Program Office Has Made Progress in Becoming 
Operational, but Is Not Fully Functioning as a Single Point of 
Accountability: 

Conclusions: 

Recommendation for Executive Action: 

Agency Comments and Our Evaluation: 

Appendix I: Scope and Methodology: 

Appendix II: Comments from the Department of Defense: 

Appendix III: Comments from the Department of Veterans Affairs: 

Appendix IV: Comments from the DOD/VA Interagency Program Office: 

Appendix V: GAO Contact and Staff Acknowledgments: 

Tables: 

Table 1: Description of DOD and VA Interoperability Objectives: 

Table 2: Status of Selected Key Activities to Establish the DOD/VA 
Interagency Program Office: 

Figure: 

Figure 1: Levels of Data Interoperability: 

Abbreviations: 

AHLTA: Armed Forces Health Longitudinal Technology Application: 

BHIE: Bidirectional Health Information Exchange: 

CDR: Clinical Data Repository: 

CHCS: Composite Health Care System: 

CHDR: interface between DOD's CDR and VA's HDR: 

DOD: Department of Defense: 

FHIE: Federal Health Information Exchange: 

HDR: Health Data Repository: 

HHS: Department of Health and Human Services: 

IT: information technology: 

VA: Department of Veterans Affairs: 

VistA: Veterans Health Information Systems and Technology Architecture: 

[End of section] 

United States Government Accountability Office: Washington, DC 20548: 

July 28, 2009: 

Congressional Committees: 

The Department of Defense (DOD) and the Department of Veterans Affairs 
(VA) have been working for over a decade on initiatives to share data 
between their health information systems. However, while they have 
taken important steps, questions have continued to be raised about when 
and to what extent the departments' intended electronic sharing 
capabilities will be fully achieved. In an effort to expedite the 
exchange of electronic health information between the two departments, 
the National Defense Authorization Act for Fiscal Year 2008[Footnote 1] 
included provisions directing DOD and VA to jointly develop and 
implement, by September 30, 2009, fully interoperable[Footnote 2] 
electronic health record systems or capabilities that are compliant 
with applicable federal interoperability standards. Such systems and 
capabilities are important for making patient information more readily 
available to health care providers in both departments, reducing 
medical errors, and streamlining administrative functions. In addition, 
the act established an interagency program office to be a single point 
of accountability for the departments' efforts. 

Further, the act directed us to assess DOD's and VA's progress in 
implementing the electronic health record systems and to report 
semiannually our results to the appropriate congressional committees. 
Accordingly, on July 28, 2008,[Footnote 3] and January 28, 2009, 
[Footnote 4] we issued reports in response to the act. As agreed with 
the committees of jurisdiction, our objectives for this third report 
are to (1) evaluate the departments' progress and plans toward 
developing electronic health record systems or capabilities that allow 
for full interoperability and comply with applicable federal 
interoperability standards and (2) determine whether the interagency 
program office established by the National Defense Authorization Act 
for Fiscal Year 2008 is positioned to function as a single point of 
accountability for developing and implementing electronic health 
records. 

To accomplish these objectives, we reviewed our past work in this area; 
analyzed current agency documentation (including plans outlining 
objectives for achieving interoperability, project status information, 
and the interagency program office charter); and conducted interviews 
with officials from DOD and VA. 

We conducted this performance audit from April 2009 through July 2009, 
in accordance with generally accepted government auditing standards. 
Those standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings and conclusions based on our audit objectives. We believe that 
the evidence obtained provides a reasonable basis for our findings and 
conclusions based on our audit objectives. For more details on our 
scope and methodology, see appendix I. 

Background: 

The use of information technology (IT) to electronically collect, 
store, retrieve, and transfer clinical, administrative, and financial 
health information has great potential to help improve the quality and 
efficiency of health care and is important to improving the performance 
of the U.S. health care system. Historically, patient health 
information has been scattered across paper records kept by many 
different caregivers in many different locations, making it difficult 
for a clinician to access all of a patient's health information at the 
time of care. Lacking access to these critical data, a clinician may be 
challenged to make the most informed decisions on treatment options, 
potentially putting the patient's health at greater risk. The use of 
electronic health records can help provide this access and improve 
clinical decisions.[Footnote 5] 

As we have previously noted,[Footnote 6] electronic health records are 
particularly crucial for optimizing the health care provided to 
military personnel and veterans. While in military status and later as 
veterans, many DOD and VA patients tend to be highly mobile and have 
health records residing at multiple medical facilities within and 
outside the United States. Making such records electronic can help 
ensure that complete health care information is available for most 
military service members and veterans at the time and place of care, no 
matter where it originates. 

Key to making health care information electronically available is 
interoperability--that is, the ability to share data among health care 
providers. Interoperability enables different information systems or 
components to exchange information and to use the information that has 
been exchanged. This capability is important because it allows 
patients' electronic health information to move with them from provider 
to provider, regardless of where the information originated. If 
electronic health records conform to interoperability standards, they 
can be created, managed, and consulted by authorized clinicians and 
staff across more than one health care organization, thus providing 
patients and their caregivers the necessary information required for 
optimal care. Paper-based health records--if available--also provide 
necessary information, but unlike electronic health records, do not 
provide decision support capabilities, such as automatic alerts about a 
particular patient's health, or other advantages of automation. 

Interoperability depends on the use of agreed-upon standards to ensure 
that information can be shared and used. In the health IT field, 
standards may govern areas ranging from technical issues, such as file 
types and interchange systems, to content issues, such as medical 
terminology. DOD and VA have agreed upon numerous common standards that 
allow them to share health data. They have also participated in 
numerous standards-setting organizations tasked to reach consensus on 
the definition and use of standards. For example, DOD and VA officials 
serve as members and are actively working on several committees and 
groups within the Healthcare Information Technology Standards Panel. 
[Footnote 7] The panel identifies and harmonizes[Footnote 8] competing 
standards and develops interoperability specifications that are needed 
for implementing the standards.[Footnote 9] 

Interoperability can be achieved at different levels.[Footnote 10] At 
the highest level, electronic data are computable (that is, in a format 
that a computer can understand and act on to, for example, provide 
alerts to clinicians on drug allergies). At a lower level, electronic 
data are structured and viewable, but not computable. The value of data 
at this level is that they are structured so that data of interest to 
users are easier to find. At still a lower level, electronic data are 
unstructured and viewable, but not computable. With unstructured 
electronic data, a user would have to find needed or relevant 
information by searching uncategorized data. Beyond these, paper 
records also can be considered interoperable (at the lowest level) 
because they allow data to be shared, read, and interpreted by human 
beings. According to DOD and VA officials, not all data require the 
same level of interoperability, nor is interoperability at the highest 
level achievable in all cases. For example, unstructured, viewable data 
may be sufficient for such narrative information as clinical notes. 
Figure 1 shows the distinction between the various levels of 
interoperability and examples of the types of data that can be shared 
at each level. 

Figure 1: Levels of Data Interoperability: 

[Refer to PDF for image: illustration] 

This figure is an illustration of levels of data interoperability, 
leading to increasingly sophisticated and standardized data, as 
follows: 

Level 1: Nonelectronic data(i.e., paper forms); 

Level 2: Unstructured, viewable electronic data(i.e., scans of paper 
forms); 

Level 3: Structured, viewable electronic data(i.e., electronically 
entered data that cannot be computed by other systems); 

Level 4: Computable electronic data(i.e., electronically entered data 
that can be computed by other systems). 

Source: GAO analysis based on data from the Center for Information 
Technology Leadership. 

[End of figure] 

DOD and VA Have Been Working to Exchange Health Information for Over a 
Decade: 

DOD and VA have been working to exchange patient health information 
electronically since 1998. We have previously noted[Footnote 11] their 
efforts on three key projects: 

* The Federal Health Information Exchange (FHIE), begun in 2001 and 
enhanced through its completion in 2004, enables DOD to electronically 
transfer service members' electronic health information to VA when the 
members leave active duty. 

* The Bidirectional Health Information Exchange (BHIE), established in 
2004, was aimed at allowing clinicians at both departments viewable 
access to records on shared patients--that is, those who receive care 
from both departments. For example, veterans may receive outpatient 
care from VA clinicians and be hospitalized at a military treatment 
facility.[Footnote 12] The interface also allows DOD sites to see 
previously inaccessible data at other DOD sites. 

* The Clinical Data Repository/Health Data Repository (CHDR) [Footnote 
13] interface, implemented in September 2006, linked the departments' 
separate repositories of standardized data to enable a two-way exchange 
of computable health information. These repositories are a part of the 
modernized health information systems that the departments have been 
developing--DOD's AHLTA[Footnote 14] and VA's HealtheVet. 

In their ongoing initiatives to share information, VA uses its 
integrated medical information system--the Veterans Health Information 
Systems and Technology Architecture (VistA)--which was developed in- 
house by VA clinicians and IT personnel.[Footnote 15] All VA medical 
facilities have access to all VistA information. 

DOD currently relies on its AHLTA, which is comprised of multiple 
legacy medical information systems that the department developed from 
commercial software products that were customized for specific uses. 
For example, CHCS, which was formerly DOD's primary health information 
system, is still in use to capture pharmacy, radiology, and laboratory 
order management.[Footnote 16] In addition, the department uses 
Essentris (also called the Clinical Information System), a commercial 
health information system customized to support inpatient treatment at 
military medical facilities. Not all of DOD's medical facilities yet 
have this inpatient medical system. 

DOD and VA Have Identified Interoperability Objectives: 

To facilitate compliance with the act, the Interagency Clinical 
Informatics Board,[Footnote 17] made up of senior clinical leaders from 
both departments who represent the user community, began establishing 
priorities for interoperable health data between DOD and VA. In this 
regard, the board is responsible for determining clinical priorities 
for electronic data sharing between the departments, as well as what 
data should be viewable and what data should be computable. Based on 
its work, the board established six interoperability objectives for 
meeting the departments' data sharing needs. According to the former 
acting director of the interagency program office, DOD and VA consider 
achievement of these six objectives, in conjunction with capabilities 
previously achieved (e.g., FHIE, BHIE, CHDR), to be sufficient to 
satisfy the requirement for full interoperability by September 2009. 
The six objectives are listed in table 1. 

Table 1: Description of DOD and VA Interoperability Objectives: 

Objective: Refine social history data; 
Description: DOD will begin sharing with VA the social history data 
that are currently captured in the DOD electronic health record. Such 
data describe, for example, patients' involvement in hazardous 
activities and tobacco and alcohol use; 
Associated interoperability level: Level 3: Structured, viewable 
electronic data. 

Objective: Share physical exam data; 
Description: DOD will provide an initial capability to share with VA 
its electronic health record information that supports the physical 
exam process when a service member separates from active military duty; 
Associated interoperability level: Level 3: Structured, viewable 
electronic data. 

Objective: Demonstrate initial network gateway operation; 
Description: DOD and VA will demonstrate the operation of the secure 
network gateways[A] to support joint DOD-VA health information sharing; 
Associated interoperability level: There is no interoperability level 
associated with this objective. 

Objective: Expand questionnaires and self-assessment tools; 
Description: DOD will provide all periodic health assessment data 
stored in its electronic health record to VA such that questionnaire 
responses are viewable with the questions that elicited them; 
Associated interoperability level: Level 3: Structured, viewable 
electronic data. 

Objective: Expand Essentris in DOD; 
Description: DOD will expand its inpatient medical records system 
(CliniComp's Essentris product suite) to at least one additional site 
in each military medical department (one Army, one Air Force, and one 
Navy for a total of three sites); 
Associated interoperability level: Level 2: Unstructured, viewable 
electronic data. 

Objective: Demonstrate initial document scanning; 
Description: DOD will demonstrate an initial capability for scanning 
service members' medical documents into its electronic health record 
and sharing the documents electronically with VA; 
Associated interoperability level: Level 2: Unstructured, viewable 
electronic data. 

Source: GAO based on DOD and VA data. 

[A] Secure network gateways provide expanded bandwidth to support 
information sharing and ensure secure and reliable data communications 
between DOD and VA health care facilities. 

[End of table] 

GAO Reports Have Highlighted the Need for DOD and VA to Address Issues 
in Their Efforts to Share Health Information: 

Our prior reports on DOD's and VA's efforts to develop fully 
interoperable electronic health records noted their progress and 
highlighted issues that they needed to address to achieve electronic 
health record interoperability. Specifically, our July 2008[Footnote 
18] report noted that the departments were sharing some, but not all, 
electronic health information at different levels of interoperability. 
At that time the departments' efforts to set up the interagency program 
office were in the early stages. Leadership positions in the office 
were not permanently filled, staffing was not complete, and facilities 
to house the office had not been designated. Accordingly, we 
recommended that the Secretaries of Defense and Veterans Affairs 
expedite efforts to put in place permanent leadership, staff, and 
facilities for the program office. The departments agreed with our 
recommendations and stated that they would take actions to address 
them. 

Our January 2009 report[Footnote 19] noted that the departments had 
defined plans to further increase their sharing of electronic health 
information; however, the plans did not contain results-oriented (i.e., 
objective, quantifiable, and measurable) performance goals and measures 
that could be used as a basis to track and assess progress. We 
recommended the departments develop and document such goals and 
performance measures for the six interoperability objectives, to use as 
the basis for future assessments and reporting of interoperability 
progress. DOD and VA agreed with our recommendation and stated that the 
departments intended to include results-oriented goals in their future 
plans. 

DOD and VA Have Taken Steps to Meet their Objectives, but Activities 
Are Expected to Remain after the Deadline for Achieving Full 
Interoperability: 

DOD and VA continue to take steps toward achieving full 
interoperability in compliance with applicable standards by September 
30, 2009. In this regard, the departments have achieved planned 
capabilities for three of the interoperability objectives--refine 
social history data, share physical exam data, and demonstrate initial 
network gateway operation. The following information further explains 
DOD's and VA's activities with respect to these three objectives. 

Refine social history data: The departments established this objective 
to enable DOD to share social history data captured in its electronic 
health record with VA. These data describe, for example, patients' 
involvement in hazardous activities and tobacco and alcohol use. Our 
review of DOD and VA project documentation confirmed that the 
departments have achieved sharing of viewable social history data, thus 
providing VA with additional clinical information on shared patients 
that clinicians could not previously view. 

Share physical exam data: The departments established this objective to 
implement an initial capability for DOD to share with VA the electronic 
health record information that supports the physical exam process when 
a service member separates from active military duty. To this end, the 
departments achieved the capability for VA to view DOD's medical exam 
data through the BHIE interface, allowing VA to view outpatient 
treatment records, pre-and post-deployment health assessments, and post-
deployment health reassessments, which are compiled for the DOD 
physical exam. 

Demonstrate initial network gateway operation: DOD and VA want to 
demonstrate the operation of secure network gateways to support health 
information sharing between the departments. These gateways are to 
support health record data exchange, thus facilitating future growth in 
data sharing. As of early July 2009, the departments reported that five 
network gateways were operational and that data migration to two of the 
operational gateways had begun.[Footnote 20] The departments believed 
these five gateways satisfy the intent of the objective and will 
provide sufficient capacity to support health information sharing 
between DOD and VA as of September 2009. The officials stated, however, 
that they anticipate needing up to four additional gateways to support 
future growth in information sharing between the departments at 
locations and dates that are to be determined. 

For the remaining three objectives, the departments have partially 
achieved planned capabilities, with additional work needed to fully 
meet the objectives. Regarding the objective to expand questionnaires 
and self-assessment tools, this additional work is intended to be 
completed by September 2009. With respect to the objectives to expand 
Essentris and demonstrate initial document scanning, department 
officials stated that they also intend to meet these objectives; 
however, additional work will be required beyond September to perform 
all the activities necessary to meet clinicians' needs for health 
information. The following information further explains the 
departments' activities with respect to these objectives. 

Expand questionnaires and self-assessment tools: The departments intend 
to provide all periodic health assessment data stored in the DOD 
electronic health record to VA in a format that associates questions 
with responses. Health assessment data are collected from two sources: 
questionnaires administered at military treatment facilities and a DOD 
health assessment reporting tool that enables patients to answer 
questions about their health upon entry into the military. Questions 
relate to a wide range of personal health information, such as dietary 
habits, physical exercise, and tobacco and alcohol use. Our review of 
the departments' project documentation determined that they have 
established the capability for VA to view questions and answers from 
the questionnaires collected by DOD at military treatment facilities; 
however, they have not yet established the capability for VA to view 
information from DOD's health assessment reporting tool. Department 
officials stated that they intend to establish this additional 
capability by September 2009. 

Expand Essentris in DOD: By September 30, 2009, DOD intends to expand 
Essentris to at least one additional site for each military service and 
to increase the percentage of inpatient discharge summaries that it 
shares electronically with VA to 63 percent.[Footnote 21] According to 
the acting director of the interagency program office, as of late June 
2009, the departments had expanded the system to two Army sites (but 
not yet to an Air Force or Navy site) and were sharing 58 percent of 
inpatient discharge summaries. The acting director stated that the 
departments expect to meet their goal of sharing 63 percent of 
inpatient discharge summaries and expand the system to an Air Force and 
a Navy site by the September deadline. Nonetheless, the official stated 
that to better meet clinicians' needs, DOD plans to further expand the 
inpatient medical records system. In this regard, the department has 
established a revised goal of making the inpatient system operational 
for 92 percent of DOD's inpatient beds by September 2010. 

Demonstrate initial document scanning: The departments intend to 
demonstrate an initial capability to scan service members' medical 
documents into the DOD electronic health record and share the documents 
electronically with VA by September 2009. According to the program 
office acting director, the departments were in the process of setting 
up an interagency test environment to test the initial capability to 
query medical documents associated with specific patients as of late 
June 2009. He stated that the departments expect to begin user testing 
at up to nine sites by September 2009. According to this official, 
these activities are expected to demonstrate initial document scanning 
capability. However, after September, the departments anticipate 
performing additional work to expand their initial document scanning 
capability (e.g., completion of user testing and deployment of the 
scanning capability at all DOD sites). 

DOD/VA Interagency Program Office Has Made Progress in Becoming 
Operational, but Is Not Fully Functioning as a Single Point of 
Accountability: 

The DOD/VA Interagency Program Office is not yet effectively positioned 
to serve as a single point of accountability for the implementation of 
fully interoperable electronic health record systems or capabilities. 
Since we last reported in January 2009, the departments have made 
progress in setting up the office by hiring additional staff, although 
they continue to fill key leadership positions on an interim basis. In 
addition, the office has begun to demonstrate responsibilities outlined 
in its charter, but is not yet fulfilling key IT management 
responsibilities in the areas of performance measurement, scheduling, 
and project planning. 

Progress Made in Staffing Interagency Program Office: 

To address the requirements set forth in the act, the departments 
identified in the September 2008 DOD/VA Information Interoperability 
Plan a schedule and key activities for setting up the interagency 
program office. Since we last reported in January 2009,[Footnote 22] 
the departments have completed all but one of the activities identified 
in their schedule. For example, they have completed personnel 
descriptions for the office's staff and have continued efforts to 
recruit and hire staff for both government and contractor positions. As 
of early July 2009, the departments had selected staff members for 10 
of 14 government positions, an increase of 8 staff since our last 
report. The acting director of the office reported that recruitment 
efforts were underway to fill the remaining 4 positions by late 
September 2009. Further, all 16 contractor positions had been filled, 
an increase of 10 contractor staff since we last reported. Table 2 
provides the status of selected key activities to establish the 
interagency program office. 

Table 2: Status of Selected Key Activities to Establish the DOD/VA 
Interagency Program Office: 

Interagency program office activities: Appoint interim acting director 
and acting deputy director; 
Due date: April 2008; 
Status as of July 2009: Complete. 

Interagency program office activities: Provide interim detailed staff, 
temporary space, and equipment; 
Due date: May 2008; 
Status as of July 2009: Complete. 

Interagency program office activities: Develop and approve the program 
office organization structure document to include mission, function, 
manpower, internal governance, accountability, and authority;
Due date: June 2008; 
Status as of July 2009: Complete. 

Interagency program office activities: Develop and approve program 
office charter or interagency agreement; 
Due date: July 2008; 
Status as of July 2009: Complete. 

Interagency program office activities: Complete resource management 
plan to include budget, space, equipment, and human resources; 
Due date: July 2008; 
Status as of July 2009: Complete. 

Interagency program office activities: Complete personnel position 
descriptions and rating schemes; 
Due date: August 2008; 
Status as of July 2009: Complete. 

Interagency program office activities: Appoint permanent director and 
deputy director; 
Due date: October 2008; 
Status as of July 2009: Not yet complete. 

Interagency program office activities: Advertise and recruit program 
staff; 
Due date: October 2008; 
Status as of July 2009: Complete. 

Source: GAO analysis of DOD and VA data. 

[End of table] 

However, while the departments have taken action toward hiring a full- 
time permanent director and a deputy director to lead the office, these 
positions continue to be filled on an interim basis. As of early July, 
DOD had selected a candidate for the director position, VA had 
concurred with the selection, and the candidate's application had been 
sent to the Office of Personnel Management for approval. In the 
meantime, the departments requested and received an extension of the 
current acting director's appointment until September 30, 2009, or 
until a permanent official is hired. Further, as of late June 2009, 
interagency program officials stated that actions were underway to fill 
the deputy director position and that VA was interviewing candidates 
for this position. According to the acting director, the departments 
anticipate making a selection for the deputy director position by the 
end of July 2009. 

Interagency Program Office Has Not Fulfilled Key Management 
Responsibilities Identified in Its Charter: 

The January 2009 interagency program office charter describes, among 
other things, the mission and function of the office associated with 
attaining interoperable electronic data. The charter further identifies 
responsibilities of the office in carrying out its mission, in areas 
such as oversight and management, stakeholder communication, and 
decision making. 

The office has taken steps toward fulfilling certain responsibilities 
described in its charter. For example, the office submitted its first 
annual report to Congress that summarized the departments' efforts 
toward achieving full interoperability and the status of key activities 
completed to set up the office. Further, the office developed 11 
standard operating procedures in areas such as program management 
oversight, strategic communications, and process improvement. 

However, the office has yet to carry out other key responsibilities 
identified in its charter that are fundamental to effective IT program 
management and that would be essential to effectively serving as the 
single point of accountability. For example, the office has not yet 
established results-oriented (i.e., objective, quantifiable, and 
measurable) goals and performance measures for all six interoperability 
objectives--an action that we previously recommended that DOD and VA 
undertake. 

Using results-oriented metrics to measure progress is an important IT 
program management activity because they can serve as a basis to 
provide meaningful information on the status of a program. As noted 
earlier, DOD and VA agreed with our recommendation calling for the 
establishment of results-oriented performance goals and measures. 
Further, the program office charter identifies the development of 
metrics to monitor the departments' performance against 
interoperability goals as a responsibility of the office. Nonetheless, 
the office has only developed such a goal for one interoperability 
objective--expand Essentris in DOD. It has not developed results- 
oriented goals and measures for the other five objectives, instead 
stating that such goals and measures will be included in the next 
version of the DOD/VA Joint Executive Council Joint Strategic Plan 
(known as the joint strategic plan), which the office expects to 
complete by December 2009. If the departments complete the development 
of results-oriented performance goals and measures for their 
interoperability objectives, they will be better positioned to gauge 
their progress toward achieving fully interoperable capabilities and 
improving veterans' health care. 

Development of an integrated master schedule is also a key IT program 
management activity, especially given the complexity of the 
departments' efforts to achieve full interoperability. According to DOD 
guidance,[Footnote 23] an integrated master schedule should identify 
detailed project tasks and the associated start, completion, and 
interim milestone dates; resource needs; and relationships (e.g., 
sequence and dependencies) between tasks. 

While the program office has begun to develop an integrated master 
schedule as required by its charter, the current version does not 
include the attributes of an effective schedule. For example, the 
schedule included limited information for three of the six 
interoperability objectives (i.e., refine social history data, share 
physical exam data, and expand questionnaires and self-assessment 
tools). Specifically, the schedule included the name of each objective 
and a completion date of September 30, 2009. However, the schedule 
contained no information on tasks to be performed to meet the 
objectives. Further, the schedule did not reflect start dates, resource 
needs, or relationships between tasks for any of the six 
interoperability objectives. Without a complete and detailed integrated 
master schedule, the departments are missing another key activity that 
could be useful in determining their progress towards achieving full 
interoperability. 

Similarly, development of a project plan is an important activity for 
IT program management. Industry best practices and IT project 
management principles stress the importance of sound planning for any 
project. Inherent in such planning is the development and use of a 
project management plan that describes, among other factors, the 
project's scope, resources, and key milestones. The interagency program 
office charter identifies the need to develop a project plan, but, as 
of late June 2009, the office had not yet done so. Without a project 
plan, the departments lack a key tool that could be used to guide their 
efforts in achieving full interoperability. 

In discussing these activities, the program office's acting director 
and former acting director cited three reasons for why performance 
measurement, scheduling, and project planning responsibilities had not 
been accomplished. First, they stated that because it has taken longer 
than anticipated to hire staff, the office has not been able to perform 
all of its responsibilities. Second, the office's interim leadership 
and staff have focused their efforts on providing to interested parties 
(e.g., federal agencies and military organizations) briefings, 
presentations, and status information on activities the office is 
undertaking to achieve interoperability, in addition to participating 
in efforts to develop a strategy for implementation of the Virtual 
Lifetime Electronic Record, which the President announced in April 
2009. Finally, according to the officials, the office waited until June 
2009 to begin the process of developing metrics so that they could do 
so in conjunction with the departments' annual update to the joint 
strategic plan that is scheduled for completion in late 2009. However, 
without metrics to monitor progress, a complete integrated master 
schedule, and a project plan, the interagency program office's ability 
to effectively provide oversight and management, including meaningful 
progress reporting on the delivery of interoperable capabilities, is 
jeopardized. Moreover, in the absence of these critical activities, the 
office is not effectively positioned to function as the single point of 
accountability for achieving full interoperability. 

Conclusions: 

DOD and VA have continued to increase electronic health information 
interoperability. In particular, the departments have taken steps to 
meet their six interoperability objectives by September 30, 2009. 
However, for two of the six interoperability objectives, the 
departments subsequently plan to perform significant additional 
activities that are necessary to meet clinicians' needs. Further, the 
departments' lack of progress in establishing fundamental IT management 
capabilities that are specific responsibilities of the interagency 
program office contributes to uncertainty about the extent to which the 
departments will progress toward achievement of full interoperability 
by the deadline. While the departments have generally made progress 
toward making the program office operational, the office has not yet 
completed a project plan or a detailed integrated master schedule. 
Without these important tools, the office is limited in its ability to 
effectively manage and provide meaningful progress reporting on the 
delivery of interoperable capabilities that are intended to improve the 
quality of health care provided to our nation's veterans. 

Recommendation for Executive Action: 

To better improve management of DOD's and VA's efforts to achieve fully 
interoperable electronic health record systems, including satisfaction 
of the departments' interoperability objectives, we recommend that the 
Secretaries of Defense and Veterans Affairs direct the Director of the 
DOD/VA Interagency Program Office to establish a project plan and a 
complete and detailed integrated master schedule. 

Agency Comments and Our Evaluation: 

In written comments on a draft of this report, the DOD official who is 
performing the duties of the Assistant Secretary of Defense (Health 
Affairs) and the Acting Director of the DOD/VA Interagency Program 
Office concurred with our findings and recommendation. The VA Chief of 
Staff also provided written comments, in which the department concurred 
with our recommendation. In this regard, DOD and VA stated that they 
will provide the necessary information for the DOD/VA Interagency 
Program Office to establish a project plan and to complete a detailed 
integrated master schedule. If the recommendation is properly 
implemented, it should better position DOD and VA to effectively 
measure and report progress in achieving full interoperability. 

Beyond its concurrence with the recommendation, the VA Chief of Staff 
stated that the department disagreed with the report's characterization 
of the six interoperability objectives and expressed concern about the 
report projecting that the objective to demonstrate initial document 
scanning would not be completed by the September 30, 2009 deadline. 
Specifically, VA stated that our report portrayed the six 
interoperability objectives as the necessary steps to achieving full 
interoperability, even though the departments consider the objectives 
to be just one component of achieving full interoperability, along with 
existing data exchange capabilities. However, in discussing the 
objectives, we stated that according to the former acting director of 
the interagency program office, the departments consider achievement of 
the six objectives, in conjunction with capabilities previously 
achieved (e.g., FHIE, BHIE, CHDR), to be sufficient to satisfy the 
requirement for full interoperability by September 2009. 

With respect to the objective to demonstrate initial document scanning, 
the Chief of Staff stated that our report projects that the objective 
will not be met by the September deadline. However, while our report 
states that according to the acting program office director, additional 
work will be required beyond September to perform all the activities 
necessary to meet clinicians' needs related to document scanning, we 
did not report that the departments would not meet this objective by 
the September deadline. In fact, our report noted that according to 
this official the departments expect to begin user testing at up to 
nine sites by September 2009, and that these activities are expected to 
demonstrate initial document scanning capability. Nonetheless, we 
revised our report as appropriate, in an attempt to more clearly 
reflect the departments' intent with regard to this objective. 

DOD, VA, and the interagency program office also provided technical 
comments on the draft report, which we incorporated as appropriate. The 
departments and the DOD/VA Interagency Program Office comments are 
reproduced in app. II, app. III, and app. IV, respectively. 

We are sending copies of this report to the Secretaries of Defense and 
Veterans Affairs, appropriate congressional committees, and other 
interested parties. In addition, the report is available at no charge 
on the GAO Web site at [hyperlink, http://www.gao.gov]. 

If you or your staffs have questions about this report, please contact 
me at (202) 512-6304 or melvinv@gao.gov. Contact points for our Offices 
of Congressional Relations and Public Affairs may be found on the last 
page of this report. Key contributors to this report are listed in 
appendix V. 

Signed by: 

Valerie C. Melvin: 
Director, Information Management and Human Capital Issues: 

List of Committees: 

The Honorable Carl Levin: 
Chairman: 
The Honorable John McCain: 
Ranking Member: 
Committee on Armed Services: 
United States Senate: 

The Honorable Daniel K. Akaka: 
Chairman: 
The Honorable Richard M. Burr: 
Ranking Member: 
Committee on Veterans' Affairs: 
United States Senate: 

The Honorable Daniel K. Inouye: 
Chairman: 
The Honorable Thad Cochran: 
Ranking Member: 
Subcommittee on Defense: 
Committee on Appropriations: 
United States Senate: 

The Honorable Tim Johnson: 
Chairman: 
The Honorable Kay Bailey Hutchison: 
Ranking Member: 
Subcommittee on Military Construction, Veterans' Affairs, and Related 
Agencies: 
Committee on Appropriations: 
United States Senate: 

The Honorable Ike Skelton: 
Chairman: 
The Honorable Howard P. "Buck" McKeon: 
Ranking Member: 
Committee on Armed Services: 
House of Representatives: 

The Honorable Bob Filner: 
Chairman: 
The Honorable Steve Buyer: 
Ranking Member: 
Committee on Veterans' Affairs: 
House of Representatives: 

The Honorable John P. Murtha: 
Chairman: 
The Honorable C.W. Bill Young: 
Ranking Member: 
Subcommittee on Defense: 
Committee on Appropriations: 
House of Representatives: 

The Honorable Chet Edwards: 
Chairman: 
The Honorable Zach Wamp: 
Ranking Member: 
Subcommittee on Military Construction, Veterans' Affairs, and Related 
Agencies: 
Committee on Appropriations: 
House of Representatives: 

[End of section] 

Appendix I: Scope and Methodology: 

To evaluate the Department of Defense's (DOD) and Veterans Affairs' 
(VA) progress toward developing electronic health record systems or 
capabilities that allow for full interoperability of personal health 
care information, we reviewed our previous work on DOD and VA efforts 
to develop health information systems, interoperable health records, 
and interoperability standards to be implemented in federal health care 
programs. We obtained and analyzed agency documentation and interviewed 
program officials to determine DOD's and VA's progress towards 
achieving full interoperability by September 30, 2009, as required by 
the National Defense Authorization Act for Fiscal Year 2008. We also 
analyzed information gathered from agency documentation to identify 
interoperability objectives, milestones, and target dates for ongoing 
and planned interoperability initiatives whose target dates extend 
beyond September 30, 2009. In addition, through interviews with 
cognizant DOD and VA officials, we obtained and assessed information 
regarding the departments' plans for achieving full interoperability of 
electronic health information. 

To determine whether the interagency program office is positioned to 
serve as a single point of accountability for developing and 
implementing electronic health records, we obtained and reviewed 
program office documentation, including its charter and standard 
operating procedures. We compared the responsibilities identified in 
the charter with actions taken by the office to exercise the 
responsibilities. Additionally, we interviewed interagency program 
office officials to determine the status of filling leadership and 
staffing positions within the office. 

We conducted this performance audit at DOD and VA locations in the 
greater Washington, D.C., metropolitan area from April through July 
2009, in accordance with generally accepted government auditing 
standards. Those standards require that we plan and perform the audit 
to obtain sufficient, appropriate evidence to provide a reasonable 
basis for our findings and conclusions based on our audit objectives. 
We believe that the evidence obtained provides a reasonable basis for 
our findings and conclusions based on our audit objectives. 

[End of section] 

Appendix II: Comments from the Department of Defense: 

Office Of The Assistant Secretary Of Defense: 
Health Affairs: 
Washington, DC 20301-1200: 

Ms. Valerie C. Melvin: 
Director, Information Management and Human Capital Issues: 
U.S. Government Accountability Office: 
441 G Street, N.W.
Washington, D.C. 20548: 

Dear Ms. Melvin: 

This is the Department of Defense (DoD) response to the GAO Draft 
Report, "GAO-09775, `Electronic Health Records: DoD and VA Efforts to 
Achieve Full Interoperability Are Ongoing; Program Office Management 
Needs Improvement,' dated July 9, 2009 (GAO Code 310935)." 

DoD acknowledges receipt of the draft audit report and concurs with the 
overall findings and recommendations. We have provided several 
suggested technical corrections in the enclosed formal response. 

Thank you for the opportunity to review and comment on the draft 
report. My points of contact for additional information are Ms. Lois 
Kellett, Lois.Kellett@tma.osd.mil or (703) 681-9530, and Mr. Gunther 
Zimmerman, Gunther.Zimmerman@tma.osd.mil or (703) 681-4360. 

Sincerely, 

Signed by: 

[Illegible], for: 

Ellen P. Embrey: 
Performing the Duties of the Assistant Secretary of Defense (Health 
Affairs): 

Enclosures: As stated: 

[End of letter] 

GAO Draft Report-Dated July 9, 2009: 
GAO 09-775 (GAO Code 310935): 

"Electronic Health Records: DoD and VA Efforts to Achieve Full 
Interoperability Are Ongoing; Program Office Management Needs 
Improvement: 

Department of Defense Comments to GAO Recommendations: 

Recommendation: To better improve management of DOD's and VA's efforts 
to achieve fully interoperable electronic health record systems, 
including satisfaction of the departments' interoperability objectives, 
we recommend that the Secretaries of Defense and Veterans Affairs 
direct the Director of the Interagency Program Office to establish a 
project plan and a complete and detailed integrated master schedule. 

DoD Response: Concur. DoD will provide the necessary information for 
the DoD/VA Interagency Program Office to establish a project plan and 
to complete a detailed integrated master schedule. 

[End of section] 

Appendix III: Comments from the Department of Veterans Affairs: 

Department of Veterans Affairs: 
Office of the Secretary: 

July 22, 2009: 

Ms. Valerie C. Melvin: 
Director, Human Capital and Management Information Systems Issues: 
U.S. Government Accountability Office: 
441 G Street, NW: 
Washington, DC 20548: 

Dear Ms. Melvin: 

The Department of Veterans Affairs (VA) has reviewed the Government 
Accountability Office's (GAO) draft report, Electronic Health Records: 
DOD and VA Efforts to Achieve Full Interoperability Are Ongoing; 
Program Office Management Needs Improvement (GAO-09-775) and concurs 
with the recommendation. Enhancing health information sharing between 
VA and the Department of Defense (DoD) is a key step towards achieving 
seamless health care for our Nation's Veterans. Fully interoperable 
electronic health data exchange will enable patient information to be 
more readily available to health care providers in both departments, 
reduce medical errors, and streamline administrative functions. 

However, I disagree with the report's portrayal of the six 
interoperability objectives established by the DoD/VA Interagency 
Clinical Informatics Board (ICIB) for meeting the Departments' data 
sharing needs. The report characterizes these objectives as the 
necessary steps to "achieve full interoperability" by the September 
2009 deadline required by Section 1635 of the Fiscal Year 2008 National 
Defense Authorization Act. Rather, VA and DoD have described the six 
interoperability objectives as just one component of achieving full 
interoperability. Furthermore, VA and DoD have already achieved a 
significant level of interoperability through existing data exchanges. 
Using the Federal and Bidirectional Health Information Exchange, VA and 
DoD already share nearly all essential health information that is 
available in electronic form. The ICIB identified the six 
interoperability objectives as additional activities that could 
leverage the existing data and interagency infrastructure already in 
existence between the Departments. The six objectives are the initial 
clinical priorities that should be in place by the September 2009 
legislative target, and taken alone, do not comprise "full 
interoperability." 

I also disagree with the report's projection that the objective to 
demonstrate an initial capability for scanning service members' medical 
documents into its electronic health record and sharing the documents 
electronically with VA will not be completed by the September 30, 2009 
deadline. 

Although VA and DoD have indicated that the Departments will perform 
additional work beyond September 2009, the Departments are on target to 
achieve all six interoperability objectives as defined by the ICIB by 
September 2009. Specifically, while the Departments will continue work 
to expand document-scanning capability beyond the initial test site, 
the completion by VA of a query and retrieval of a DoD scanned document 
in an interagency test environment will complete the interoperability 
objective as defined by the ICIB. 

Beyond September 2009, VA will work with DoD to identify additional 
electronic health information that should be shared. The Departments' 
future work will be based on the clinical priorities identified by the 
ICIB. Additionally, the Departments continue active participation on 
the national effort led by the National Coordinator for Health 
Information Technology. This work will ensure that VA and DoD's 
interoperable electronic health record systems remain aligned with the 
national strategy for interoperability. 

The enclosure addresses GAO's recommendation and provides additional 
comments to the draft report. VA appreciates the opportunity to comment 
on your draft report. 

Sincerely, 

Signed by: 

John R. Gingrich: 
Chief of Staff: 

Enclosure: 

[End of letter] 

Enclosure: 

Department of Veterans Affairs (VA): 
Comments on Government Accountability Office (GAO) Draft Report: 

Electronic Health Records: DOD and VA Efforts to Achieve Full 
Interoperability Are Ongoing; Program Office Management Needs 
Improvement (GAO-09-775): 

GAO Recommendation: To better improve management of DOD's and VA's 
efforts to achieve fully interoperable electronic health records 
systems, including satisfaction of the departments' interoperability 
objectives, [GAO] recommends that the Secretaries of Defense and 
Veterans Affairs direct the Director of the Interagency Program Office 
to establish a project plan and a complete and detailed integrated 
master schedule. 

Response: Concur. VA and DoD are coordinating on an integrated master 
schedule and more detailed joint project plan that will permit the 
Interagency Program Office (IPO) to carry out the functions identified 
in its charter. The project plan will include the level of information 
that is agreed to by VA and DoD. VA will work with the IPO and DoD to 
provide a copy of the project plan, including key information 
concerning interoperability project dependencies and risks, to GAO upon 
completion of an internal review by appropriate information technology 
and management execution offices.
Additional comments: 

Throughout the Draft Report (e.g., page 1 summary paragraph; pages 13-
14), GAO projects that the Departments will not be able to complete the 
following objective by the September 30, 2009, deadline: DoD 
demonstrate an initial capability for scanning service members' medical 
documents into its electronic health record and sharing the documents 
electronically with VA. 

VA Comment: Although VA and DoD have indicated that the Departments 
will perform additional work beyond September 2009, the Departments are 
on target to achieve all six interoperability objectives as defined by 
the ICIB by September 2009. 

VA does not concur with the finding on page 14 that the Departments 
will need to perform additional work to expand their initial document 
scanning capability to all DoD sites in order to meet the 
interoperability objective. VA recommends that GAO edit the paragraph 
to state: "Although the Departments will continue work to expand 
document scanning capability beyond the initial test site, the 
completion by VA of a query and retrieval of a DoD scanned document in 
an interagency test environment will complete the interoperability 
objective as defined by the ICIB." 

On page 8, the paragraph concerning FHIE should reflect that VA and DoD 
first developed data sharing in 2001 and enhanced the FHIE one-way data 
exchange through 2004 when BHIE was first implemented. 

On pages 14-19, GAO raises issues regarding key management 
responsibilities of the IPO. 

VA comment: the IPO charter will be revised to address GAO's concerns 
about identifying specific IPO management responsibilities. 

[End of section] 

Appendix IV: Comments from the DOD/VA Interagency Program Office: 

DoD/VA Interagency Program Office: 
1700 North Moore Street: 
Rosslyn, VA 22209: 

July 16, 2009: 

Ms. Valerie C. Melvin: 
Director, Information Management & Human Capital Issues: 
U.S. Government Accountability Office: 
441 G Street, N.W. 
Washington, D.C. 20548: 

Dear Ms. Melvin: 

This is the DoD/VA Interagency Program Office's (IPO) response to the 
recommendations enclosed in the Government Accountability Office (GAO) 
Draft Report, "Electronic Health Records: DoD and VA Efforts to Achieve 
Full Interoperability Are Ongoing; Program Office Management Needs 
Improvement," July 9, 2009, (Project No. GAO-09-775, GAO Code 310935). 

IPO acknowledges receipt of the draft audit report and concurs with the 
overall findings and recommendations. We have provided several 
suggested technical corrections in the enclosed formal response. 

Thank you for the opportunity to review and comment on the draft 
report. My points of contact for additional information are Mr. Cliff 
Freeman at Cliff.Freeman@va.gov, 703-696-0216; Mr. Kevin Tewes, 
Kevin.Tewes@osd.mil, 703696-2856; and Mr. Ryan Cool, Rvan.Cool@osd.mil, 
703-696-3636. 

Sincerely, 

Signed by: 

Gregory Timberlake: 
RADM, SHCE, USN: 
Director, DoD/VA Interagency Program Office: 

Enclosures: As stated: 

[End of letter] 

GAO Draft Report-Dated July 9, 2009: 
GAO 09-775 (GAO Code 310935): 

"Electronic Health Records: DoD and VA Efforts to Achieve Full 
Interoperability Are Ongoing; Program Office Management Needs 
Improvement" 

IPO Comments to GAO Recommendations: 

GAO Recommendation: "To better improve management of DOD's and VA's 
efforts to achieve fully interoperable electronic health record 
systems, including satisfaction of the departments' interoperability 
objectives, we recommend that the Secretaries of Defense and Veterans 
Affairs direct the Director of the Interagency Program Office to 
establish a project plan and a complete and detailed integrated master 
schedule." 

IPO Response: Concur. The IPO will establish a project plan and 
complete a detailed integrated master schedule. DoD and VA should 
provide the IPO with the information that it requires to accomplish 
these tasks. 

[End of section] 

Appendix V: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Valerie C. Melvin, (202) 512-6304 or melvinv@gao.gov: 

Staff Acknowledgments: 

In addition to the contact named above, key contributions to this 
report were made by Mark Bird, Assistant Director; Rebecca Eyler; Lee 
McCracken; Michael Redfern; J. Michael Resser; Kelly Shaw; Eric Trout; 
and Merry Woo. 

[End of section] 

Footnotes: 

[1] Pub. L. No. 110-181, § 1635 (2008). 

[2] Interoperability is the ability of two or more systems or 
components to exchange information and to use the information that has 
been exchanged. 

[3] See GAO, Electronic Health Records: DOD and VA Have Increased Their 
Sharing of Health Information, but More Work Remains, [hyperlink, 
http://www.gao.gov/products/GAO-08-954] (Washington, D.C.: July 28, 
2008). In this report, we highlighted the departments' progress in 
sharing electronic health information, developing electronic records 
that comply with national standards, and setting up the interagency 
program office. 

[4] See GAO, Electronic Health Records: DOD's and VA's Sharing of 
Information Could Benefit from Improved Management, [hyperlink, 
http://www.gao.gov/products/GAO-09-268] (Washington, D.C.: Jan. 28, 
2009). In this report, we noted that DOD and VA have increased their 
sharing of health information, and defined plans to further increase 
their sharing of electronic health information. However, the plans did 
not identify results-oriented (i.e., objective, quantifiable, and 
measurable) performance goals and measures that are characteristic of 
effective planning. 

[5] An electronic health record is a collection of information about 
the health of an individual or the care provided, such as patient 
demographics, progress notes, problems, medications, vital signs, past 
medical history, immunizations, laboratory data, and radiology reports. 

[6] [hyperlink, http://www.gao.gov/products/GAO-09-268]. 

[7] The panel was established in October 2005 as a public-private 
partnership funded by the Office of the National Coordinator. This 
panel is sponsored by the American National Standards Institute, which 
is a private, nonprofit organization whose mission is to promote and 
facilitate voluntary consensus standards and ensure their integrity. 

[8] Harmonization is the process of identifying overlaps and gaps in 
relevant standards and developing recommendations to address these 
overlaps and gaps. 

[9] Developing, coordinating, and agreeing on standards are only part 
of the processes involved in achieving interoperability for electronic 
health records systems or capabilities. In addition, specifications are 
needed for implementing the standards, as well as criteria and a 
process for verifying compliance with the standards. An 
interoperability specification codifies detailed implementation 
guidance that includes references to the identified standards or parts 
of standards and explains how they should be applied to specific health 
care topic areas. 

[10] These levels were identified by the Center for Information 
Technology Leadership, which was chartered in 2002 as a research 
organization established to help guide the health care community in 
making more informed strategic IT investment decisions. According to 
DOD and VA, the different levels of interoperability have been accepted 
for use by the Office of the National Coordinator for Health 
Information Technology. 

[11] [hyperlink, http://www.gao.gov/products/GAO-08-954]. 

[12] To create BHIE, the departments drew on the architecture and 
framework of the information transfer system established by the FHIE 
project. Unlike FHIE, which provides a one-way transfer of information 
to VA when a service member separates from the military, the two-way 
interface allows clinicians in both departments to view, in real time, 
limited health data (in text form) from the departments' existing 
health information systems. 

[13] The name CHDR, pronounced "cheddar," combines the names of the two 
repositories. 

[14] The department considers AHLTA the official name of the system. 
(It was formerly an abbreviation for Armed Forces Health Longitudinal 
Technology Application.) Previously, AHLTA was known as the Composite 
Health Care System II (or CHCS II). 

[15] VistA began operation in 1983 as the Decentralized Hospital 
Computer Program. In 1996, the name of the system was changed to the 
Veterans Health Information Systems and Technology Architecture. 

[16] According to DOD, CHCS applications are now accessed through its 
modernized health information system, AHLTA. 

[17] This board was originally named the Joint Clinical Information 
Board. 

[18] [hyperlink, http://www.gao.gov/products/GAO-08-954]. 

[19] [hyperlink, http://www.gao.gov/products/GAO-09-268]. 

[20] The five operational gateways are located in Dallas, Texas; 
Reston, Virginia; Kansas City, Missouri; North Chicago, Illinois; and 
Santa Clara, California. 

[21] DOD and VA previously reported this goal at 70 percent, but in 
comments to our report, stated a revised goal of 63 percent. 

[22] [hyperlink, http://www.gao.gov/products/GAO-09-268]. 

[23] DOD Integrated Master Plan and Integrated Master Schedule 
Preparation and Use Guide, Version 0.9, October 21, 2005. 

[End of section] 

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