Computer-Based Patient Records:

VA and DOD Efforts to Exchange Health Data Could Benefit from Improved Planning and Project Management

GAO-04-687: Published: Jun 7, 2004. Publicly Released: Jul 7, 2004.

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A critical element of the Department of Veterans Affairs' (VA) information technology program is its continuing work with the Department of Defense (DOD) to achieve the ability to exchange patient health care information and create electronic medical records for use by veterans, active-duty military personnel, and their health care providers.

While VA and DOD continue to move forward in agreeing to and adopting standards for clinical data, they have made little progress since last winter toward defining how they intend to achieve an electronic medical record based on the two-way exchange of patient health data. The departments continue to face significant challenges in achieving this capability. VA and DOD lack an explicit architecture--a blueprint--that provides details on what specific technologies will be used to achieve the electronic medical record by the end of 2005. The departments have not fully implemented a project management structure that establishes lead decision-making authority and ensures the necessary day-to-day guidance of and accountability for their investment in and implementation of this project. They are operating without a project management plan describing the specific responsibilities of each department in developing, testing, and deploying the electronic interface. In seeking to provide a two-way exchange of health information between their separate health information systems, VA and DOD have chosen a complex and challenging approach--one that necessitates the highest levels of project discipline. Yet critical project components are currently lacking. As such, the departments risk investing in a capability that could fall short of what is expected and what is needed. Until a clear approach and sound planning are made integral parts of this initiative, concerns about exactly what capabilities VA and DOD will achieve--and when--will remain.

Status Legend:

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  • Review Pending-GAO has not yet assessed implementation status.
  • Open-Actions to satisfy the intent of the recommendation have not been taken or are being planned, or actions that partially satisfy the intent of the recommendation have been taken.
  • Closed-implemented-Actions that satisfy the intent of the recommendation have been taken.
  • Closed-not implemented-While the intent of the recommendation has not been satisfied, time or circumstances have rendered the recommendation invalid.
    • Review Pending
    • Open
    • Closed - implemented
    • Closed - not implemented

    Recommendations for Executive Action

    Recommendation: The Secretaries of Veterans Affairs and Defense should instruct the Acting Chief Information Officer for Health and the Chief Information Officer for the Military Health System, respectively, to create and implement a comprehensive and coordinated project management plan for the electronic interface that defines the technical and managerial processes necessary to satisfy project requirements and includes (1) the authority and responsibility of each organizational unit; (2) a work breakdown structure for all of the tasks to be performed in developing, testing, and implementing the software, along with schedules associated with the tasks; and (3) a security policy.

    Agency Affected: Department of Defense

    Status: Closed - Implemented

    Comments: In September 2008, the Department of Veterans Affairs, in conjunction with the Department of Defense, produced its initial version of a project plan for achieving the two-way exchange of health information. The plan generally describes the departments' vision, guiding principles, achievements to date, initiatives, organizational roles, and high-level timelines. Additionally, the plan includes information about the authority and responsibility of the interagency office being established to manage the departments' health care information interoperability program, and it contains descriptive information about interoperability standards and generally recognized interoperability levels. Finally, the plan includes milestones for requirements validation, acquisition, testing, and implementation of selected short-term interoperability initiatives. According to DOD and VA officials, subsequent versions of the plan are expected to include additional and more detailed information regarding the departments' efforts to share electronic health information.

    Recommendation: The Secretaries of Veterans Affairs and Defense should instruct the Acting Chief Information Officer for Health and the Chief Information Officer for the Military Health System, respectively, to establish a project management structure to provide day-to-day guidance of and accountability for their investments in and implementation of the interface capability

    Agency Affected: Department of Defense

    Status: Closed - Implemented

    Comments: The Departments of Veterans Affairs and Defense concurred with and implemented this recommendation. The departments have implemented a joint project management structure, consisting of a Program Manager from VA and a Deputy Program Manager from DOD. Additionally, the December 2004 Shared Health Architecture document states that the HEC established the DoD/VA Information Management/Information Technology Working Group to provide programmatic oversight and the DoD/VA Health Architecture Interagency Group, which is a sub-group of the IM/IT Working Group, to facilitate interagency cooperation collaboration on enterprise architecture sharing initiatives between DoD and VA. Collectively, the designated program manager, in conjunction with these groups, provide day-to-day responsibility for project implementation and minimizing the duplication of systems and services. Finally, the Departments are using monthly interim process reviews to provide accountability for their investments in and implementation of the interface capability.

    Recommendation: The Secretaries of Veterans Affairs and Defense should instruct the Acting Chief Information Officer for Health and the Chief Information Officer for the Military Health System, respectively, to establish a project management structure to provide day-to-day guidance of and accountability for their investments in and implementation of the interface capability

    Agency Affected: Department of Veterans Affairs

    Status: Closed - Implemented

    Comments: The Departments of Veterans Affairs and Defense concurred with and implemented this recommendation. The departments have implemented a joint project management structure, consisting of a Program Manager from VA and a Deputy Program Manager from DOD. Additionally, the December 2004 Shared Health Architecture document states that the HEC established the DoD/VA Information Management/Information Technology Working Group to provide programmatic oversight and the DoD/VA Health Architecture Interagency Group, which is a sub-group of the IM/IT Working Group, to facilitate interagency cooperation collaboration on enterprise architecture sharing initiatives between DoD and VA. Collectively, the designated program manager, in conjunction with these groups, provide day-to-day responsibility for project implementation and minimizing the duplication of systems and services. Finally, the Departments are using monthly interim process reviews to provide accountability for their investments in and implementation of the interface capability.

    Recommendation: The Secretaries of Veterans Affairs and Defense should instruct the Acting Chief Information Officer for Health and the Chief Information Officer for the Military Health System, respectively, to select a lead entity with final decision-making authority for the initiative.

    Agency Affected: Department of Defense

    Status: Closed - Implemented

    Comments: The departments concurred with and have taken actions to address the recommendation. As we reported in June 2006, the departments established project accountability and implemented a joint project management structure. Specifically, the Health Executive Council was established as the lead entity for the project. The joint project management structure consists of a Program Manager from VA and a Deputy Program Manager from DOD to provide day-to-day guidance for this initiative. By creating this management structure, the departments have taken a positive step towards achieving the goals of this initiative and developing a point of accountability for future project milestones.

    Recommendation: The Secretaries of Veterans Affairs and Defense should instruct the Acting Chief Information Officer for Health and the Chief Information Officer for the Military Health System, respectively, to select a lead entity with final decision-making authority for the initiative.

    Agency Affected: Department of Veterans Affairs

    Status: Closed - Implemented

    Comments: The departments concurred with and have taken actions to address the recommendation. As we reported in June 2006, the departments established project accountability and implemented a joint project management structure. Specifically, the Health Executive Council was established as the lead entity for the project. The joint project management structure consists of a Program Manager from VA and a Deputy Program Manager from DOD to provide day-to-day guidance for this initiative. By creating this management structure the departments have taken a positive step towards achieving the goals of this initiative and developing a point of accountability for future project milestones.

    Recommendation: To encourage significant progress on achieving the two-way exchange of health information, the Secretaries of Veterans Affairs and Defense should instruct the Acting Chief Information Officer for Health and the Chief Information Officer for the Military Health System, respectively, to develop an architecture for the electronic interface between their health systems that includes system requirements, design specifications, and software descriptions.

    Agency Affected: Department of Veterans Affairs

    Status: Closed - Implemented

    Comments: The departments agreed with the recommendation and in August 2005 provided documentation (Concept of Operations, Interface Control Document, and Interface Design Description) on the architecture developed for the Clinical/Health Data Repository interface that includes the major elements required in a complete architecture. For example, it defines system requirements and allows these to be traced to the functional requirements, includes the design and control specifications for the interface design, and includes design descriptions for the software.

    Recommendation: To encourage significant progress on achieving the two-way exchange of health information, the Secretaries of Veterans Affairs and Defense should instruct the Acting Chief Information Officer for Health and the Chief Information Officer for the Military Health System, respectively, to develop an architecture for the electronic interface between their health systems that includes system requirements, design specifications, and software descriptions.

    Agency Affected: Department of Defense

    Status: Closed - Implemented

    Comments: The departments agreed with the recommendation and in August 2005 provided documentation (Concept of Operations, Interface Control Document, and Interface Design Description) on the architecture developed for the Clinical/Health Data Repository interface that includes the major elements required in a complete architecture. For example, it defines system requirements and allows these to be traced to the functional requirements, includes the design and control specifications for the interface design, and includes design descriptions for the software.

    Recommendation: The Secretaries of Veterans Affairs and Defense should instruct the Acting Chief Information Officer for Health and the Chief Information Officer for the Military Health System, respectively, to create and implement a comprehensive and coordinated project management plan for the electronic interface that defines the technical and managerial processes necessary to satisfy project requirements and includes (1) the authority and responsibility of each organizational unit; (2) a work breakdown structure for all of the tasks to be performed in developing, testing, and implementing the software, along with schedules associated with the tasks; and (3) a security policy.

    Agency Affected: Department of Veterans Affairs

    Status: Closed - Implemented

    Comments: In September 2008, the Department of Defense, in conjunction with the Department of Veterans Affairs, produced its initial version of a project plan for achieving the two-way exchange of health information. The plan generally describes the departments' vision, guiding principles, achievements to date, initiatives, organizational roles, and high-level timelines. Additionally, the plan includes information about the authority and responsibility of the interagency office being established to manage the departments' health care information interoperability program, and it contains descriptive information about interoperability standards and generally recognized interoperability levels. Finally, the plan includes milestones for requirements validation, acquisition, testing, and implementation of selected short-term interoperability initiatives. According to DOD and VA officials, subsequent versions of the plan are expected to include additional and more detailed information regarding the departments' efforts to share electronic health information.

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