Electronic Health Records:

DOD and VA Should Remove Barriers and Improve Efforts to Meet Their Common System Needs

GAO-11-265: Published: Feb 2, 2011. Publicly Released: Feb 2, 2011.

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The Department of Defense (DOD) and the Department of Veterans Affairs (VA) operate two of the nation's largest health care systems. To do so, both departments rely on electronic health record systems to create, maintain, and manage patient health information. DOD and VA are currently undertaking initiatives to modernize their respective systems, jointly establish the Virtual Lifetime Electronic Record (VLER), and develop joint information technology (IT) capabilities for the James A. Lovell Federal Health Care Center (FHCC). In light of these efforts, GAO was asked to (1) identify any barriers that DOD and VA face in modernizing their electronic health record systems to jointly address their common health care business needs, and (2) identify lessons learned from DOD's and VA's efforts to jointly develop VLER and to meet the health care information needs for the FHCC. To do this, GAO analyzed departmental reviews and other documentation and interviewed DOD and VA officials.

DOD and VA face barriers in three key IT management areas--strategic planning, enterprise architecture, and investment management--and, as a result, lack mechanisms for identifying and implementing efficient and effective IT solutions to jointly address their common health care system needs. First, the departments have been unable to articulate explicit plans, goals, and timeframes for jointly addressing the health IT requirements common to both departments' electronic health record systems. For example, DOD's and VA's joint strategic plan does not discuss how or when the departments propose to identify and develop joint health IT solutions, and department officials have not yet determined whether the IT capabilities developed for the FHCC can or will be implemented at other DOD and VA medical facilities. Second, although DOD and VA have taken steps toward developing and maintaining artifacts related to a joint health architecture (i.e., a description of business processes and supporting technologies), the architecture is not sufficiently mature to guide the departments' joint health IT modernization efforts. For example, the departments have not defined how they intend to transition from their current architecture to a planned future state. Third, DOD and VA have not established a joint process for selecting IT investments based on criteria that consider cost, benefit, schedule, and risk elements, which would help to ensure that the chosen solution both meets the departments' common health IT needs and provides better value and benefits to the government as a whole. These barriers result in part from DOD's and VA's decision to focus on developing VLER, modernizing their separate electronic health record systems, and developing IT capabilities for the FHCC, rather than determining the most efficient and effective approach to jointly addressing their common requirements. Because DOD and VA continue to pursue their existing health information sharing efforts without fully establishing the key IT management capabilities described above, they may be missing opportunities to successfully deploy joint solutions to address their common health care business needs. DOD's and VA's experiences in developing VLER and IT capabilities for the FHCC offer important lessons that the departments can use to improve their management of these ongoing efforts. Specifically, the departments can improve the likelihood of successfully meeting their goal to implement VLER nationwide by the end of 2012 by developing an approved plan that is consistent with effective IT project management principles. Also, DOD and VA can improve their continuing effort to develop and implement new IT system capabilities for the FHCC by developing a plan that defines the project's scope, estimated cost, and schedule in accordance with established best practices. Unless DOD and VA address these lessons, the departments will jeopardize their ability to deliver expected capabilities to support their joint health IT needs. GAO is recommending that DOD and VA take steps to improve their joint strategic planning, enterprise architecture, and IT investment management to address their common health care business needs. GAO is also recommending that the departments strengthen their joint IT system planning efforts for VLER and the FHCC. Commenting on a draft of this report, DOD, VA, and the DOD/VA Interagency Program Office concurred with GAO's recommendations.

Recommendations for Executive Action

  1. Status: Open

    Comments: In March 2013, the Departments of Defense (DOD) and Veterans Affairs (VA) released their joint strategic plan for fiscal years 2013 through 2015, as GAO recommended in February 2011. The plan described the departments' intentions to pursue a single electronic health record system. However, 1 month earlier, in February 2013, the departments abandoned the single system approach and now intend to separately modernize their electronic health record systems. As a result, the plan's discussion of the single-system effort is no longer relevant. In July 2013, the VA/DOD Joint Executive Council tasked the DOD and VA Interagency Program Office with preparing an addendum to the joint strategic plan that would reflect the departments' revised joint activities, milestones, metrics, and timelines for creating an interoperable health record. Yet, while the departments have begun their separate electronic health record modernization efforts and have identified the need to make these systems interoperable, they have not revised their plan for doing so. According to DOD and VA officials, as of January 2014, a draft addendum to the joint strategic plan was being reviewed by the departments' senior leaders, but the officials could not say when the addendum is to be finalized. Until DOD and VA provide a revised plan that reflects their current approach, the departments and their stakeholders may not have a shared understanding of how they intend to address their common health care business needs going forward.

    Recommendation: To ensure that DOD and VA efficiently and effectively modernize their electronic health record systems to jointly address their common health care business needs, the Secretaries of Defense and Veterans Affairs should direct the Joint Executive Council to revise the departments' joint strategic plan to include information discussing their electronic health record system modernization efforts and how those efforts will address the departments' common health care business needs.

    Agency Affected: Department of Defense

  2. Status: Open

    Comments: In March 2013, the Departments of Defense (DOD) and Veterans Affairs (VA) released their joint strategic plan for fiscal years 2013 through 2015, as GAO recommended in February 2011. The plan described the departments' intentions to pursue a single electronic health record system. However, 1 month earlier, in February 2013, the departments had abandoned the single system approach and now intend to separately modernize their electronic health record systems. As a result, the plan's discussion of the single-system effort is no longer relevant. In July 2013, the VA/DOD Joint Executive Council tasked the DOD and VA Interagency Program Office with preparing an addendum to the joint strategic plan that would reflect the departments' revised joint activities, milestones, metrics, and timelines for creating an interoperable health record. However, while the departments have begun their separate electronic health record modernization efforts and have identified the need to make these systems interoperable, they have not revised their plan for doing so. According to DOD and VA officials, as of January 2014, a draft addendum to the joint strategic plan was being reviewed by the departments' senior leaders, but the officials could not say when the addendum is to be finalized. Until DOD and VA provide a revised plan that reflects their current approach, the departments and their stakeholders may not have a shared understanding of how they intend to address their common health care business needs going forward.

    Recommendation: To ensure that DOD and VA efficiently and effectively modernize their electronic health record systems to jointly address their common health care business needs, the Secretaries of Defense and Veterans Affairs should direct the Joint Executive Council to revise the departments' joint strategic plan to include information discussing their electronic health record system modernization efforts and how those efforts will address the departments' common health care business needs.

    Agency Affected: Department of Veterans Affairs

  3. Status: Open

    Comments: The Departments of Defense (DOD) and Veterans Affairs (VA) have not further developed a joint health architecture that could guide their efforts to address their common health care business needs, as GAO recommended in February 2011. The departments had undertaken certain actions, but these have been overtaken by events or are tangential to developing the architecture; thus progress in addressing GAO's recommendation has slowed. For example, in January 2013, the Interagency Program Office (IPO) developed an Enterprise Architecture Management Plan to provide guidance for developing joint architecture products, identify architecture governance bodies and stakeholder responsibilities, and propose high-level timelines for architecture-related activities. However, according to DOD and VA officials, this plan is no longer operative because it does not reflect the departments' decision to pursue separate electronic health record system modernization efforts. In addition, in December 2013 the departments revised the charter of their IPO, which describes the importance of identifying and adopting health information technology (IT) standards to seamlessly integrate DOD and VA health care record data. The charter also specifies that the IPO is responsible for working with the departments' Health Architecture Review Board to ensure that both departments are appropriately synchronized and coordinated. While these recent activities are peripherally related to development of the joint health architecture, DOD and VA have not yet developed architecture artifacts that describe their planned future state and how they intend to transition to that future state. Until the departments have an understanding of the common business processes and technologies that a joint health architecture can provide, they will continue to lack an essential tool for jointly addressing their common health IT needs.

    Recommendation: To ensure that DOD and VA efficiently and effectively modernize their electronic health record systems to jointly address their common health care business needs, the Secretaries of Defense and Veterans Affairs should direct the Joint Executive Council to further develop the departments' joint health architecture to include their planned future (i.e., "to be") state and a sequencing plan for how they intend to transition from their current state to the next generation of electronic health record capabilities.

    Agency Affected: Department of Veterans Affairs

  4. Status: Open

    Comments: The Departments of Defense (DOD) and Veterans Affairs (VA) have not further developed a joint health architecture that could guide their efforts to address their common health care business needs, as GAO recommended in February 2011. The departments had undertaken certain actions, but these have been overtaken by events or are tangential to developing the architecture; thus progress in addressing GAO's recommendation has slowed. For example, in January 2013, the Interagency Program Office (IPO) developed an Enterprise Architecture Management Plan to provide guidance for developing joint architecture products, identify architecture governance bodies and stakeholder responsibilities, and propose high-level timelines for architecture-related activities. However, according to DOD and VA officials, this plan is no longer operative because it does not reflect the departments' decision to pursue separate electronic health record system modernization efforts. In addition, in December 2013 the departments revised the charter of their IPO, which describes the importance of identifying and adopting health information technology (IT) standards to seamlessly integrate DOD and VA health care record data. The charter also specifies that the IPO is responsible for working with the departments' Health Architecture Review Board to ensure that both departments are appropriately synchronized and coordinated. While these recent activities are peripherally related to development of the joint health architecture, DOD and VA have not yet developed architecture artifacts that describe their planned future state and how they intend to transition to that future state. Until the departments have an understanding of the common business processes and technologies that a joint health architecture can provide, they will continue to lack an essential tool for jointly addressing their common health IT needs.

    Recommendation: To ensure that DOD and VA efficiently and effectively modernize their electronic health record systems to jointly address their common health care business needs, the Secretaries of Defense and Veterans Affairs should direct the Joint Executive Council to further develop the departments' joint health architecture to include their planned future (i.e., "to be") state and a sequencing plan for how they intend to transition from their current state to the next generation of electronic health record capabilities.

    Agency Affected: Department of Defense

  5. Status: Open

    Comments: The Departments of Defense (DOD) and Veterans Affairs (VA) initiated, but did not sustain, two courses of action that were potentially responsive to GAO's February 2011 recommendation; thus, progress in addressing GAO's recommendation has slowed. First, the departments established the Interagency Program Office (IPO) advisory board in October 2011 to monitor the integrated electronic health record (iEHR) program's progress toward meeting cost, schedule, and performance milestones. However, the advisory board did not meet after June 2013 and was disbanded as a result of the departments' decision to pursue separate modernizations of their electronic health record systems. Second, in August 2012, the departments established a working group under the Interagency Clinical Informatics Board to identify potential health IT investments for the departments to consider for joint adoption. However, the group has not met since June 2013, and according to DOD and VA officials, its activities have been suspended while the departments continue to define their separate modernization efforts and their electronic health data interoperability needs. Moreover, the group was not involved in helping the departments identify and select the separate electronic health record investments DOD and VA now plan to undertake to meet their common health care business needs. Because DOD and VA have not implemented a process for identifying and selecting joint IT investments, the departments have not demonstrated that their approach to meeting their common health care business needs has considered the costs, benefits, schedule, and risks of planned investments. As a result, VA and DOD lack reasonable assurance that they are pursuing the most cost-effective and timely course of action for delivering a fully interoperable electronic health record to provide the best possible care for service members and veterans.

    Recommendation: To ensure that DOD and VA efficiently and effectively modernize their electronic health record systems to jointly address their common health care business needs, the Secretaries of Defense and Veterans Affairs should direct the Joint Executive Council to define and implement a process, including criteria that considers costs, benefits, schedule, and risks, for identifying and selecting joint IT investments to meet the departments' common health care business needs.

    Agency Affected: Department of Veterans Affairs

  6. Status: Open

    Comments: The Departments of Defense (DOD) and Veterans Affairs (VA) initiated, but did not sustain, two courses of action that were potentially responsive to GAO's February 2011 recommendation; thus, progress in addressing GAO's recommendation has slowed. First, the departments established the Interagency Program Office (IPO) advisory board in October 2011 to monitor the integrated electronic health record (iEHR) program's progress toward meeting cost, schedule, and performance milestones. However, the advisory board did not meet after June 2013 and was disbanded as a result of the departments' decision to pursue separate modernizations of their electronic health record systems. Second, in August 2012, the departments established a working group under the Interagency Clinical Informatics Board to identify potential health IT investments for the departments to consider for joint adoption. However, the group has not met since June 2013, and according to DOD and VA officials, its activities have been suspended while the departments continue to define their separate modernization efforts and their electronic health data interoperability needs. Moreover, the group was not involved in helping the departments identify and select the separate electronic health record investments DOD and VA now plan to undertake to meet their common health care business needs. Because DOD and VA have not implemented a process for identifying and selecting joint IT investments, the departments have not demonstrated that their approach to meeting their common health care business needs has considered the costs, benefits, schedule, and risks of planned investments. As a result, VA and DOD lack reasonable assurance that they are pursuing the most cost-effective and timely course of action for delivering a fully interoperable electronic health record to provide the best possible care for service members and veterans.

    Recommendation: To ensure that DOD and VA efficiently and effectively modernize their electronic health record systems to jointly address their common health care business needs, the Secretaries of Defense and Veterans Affairs should direct the Joint Executive Council to define and implement a process, including criteria that considers costs, benefits, schedule, and risks, for identifying and selecting joint IT investments to meet the departments' common health care business needs.

    Agency Affected: Department of Defense

  7. Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

    Recommendation: The Secretaries of Defense and Veterans Affairs should strengthen their ongoing efforts to establish VLER and the joint IT system capabilities for the FHCC by developing plans that include scope definition, cost and schedule estimation, and project plan documentation and approval.

    Agency Affected: Department of Defense

  8. Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

    Recommendation: The Secretaries of Defense and Veterans Affairs should strengthen their ongoing efforts to establish VLER and the joint IT system capabilities for the FHCC by developing plans that include scope definition, cost and schedule estimation, and project plan documentation and approval.

    Agency Affected: Department of Veterans Affairs

 

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