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: Closed - Not Implemented

    Comments: The Departments of Defense (DOD) and Veterans Affairs (VA) released their joint strategic plan for fiscal years 2013 through 2015 in March 2013. 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 have since taken actions to separately modernize their electronic health record systems. As a result, the plan's discussion of the single-system effort is no longer relevant.

    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: Closed - Not Implemented

    Comments: The Departments of Defense (DOD) and Veterans Affairs (VA) released their joint strategic plan for fiscal years 2013 through 2015 in March 2013. 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 have since taken actions to separately modernize their electronic health record systems. As a result, the plan's discussion of the single-system effort is no longer relevant.

    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: Closed - Not Implemented

    Comments: 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 Department of Defense and Veterans Affairs officials, this plan is no longer operative because it does not reflect the departments' decision to pursue separate electronic health record system modernization efforts.

    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: Closed - Not Implemented

    Comments: 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 Department of Defense and Veterans Affairs officials, this plan is no longer operative because it does not reflect the departments' decision to pursue separate electronic health record system modernization efforts.

    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: Closed - Not Implemented

    Comments: The Departments of Defense (DOD) and Veterans Affairs (VA) have not developed a process for identifying and selecting joint IT investments. DOD and VA senior leaders agreed to develop separate electronic health record solutions that adhere to the same body of technical standards, terminologies, and guidance for interoperability set forth by the Interagency Program Office. VA noted in its September 2014 recommendation status update that given these commitments, the departments' respective solutions should yield interoperable information exchanges, without the need to invest in other joint technologies. Further, as a result of the departments' strategy to implement "separate but interoperable systems," VA asserts that the concept of a joint IT investment approach is no longer practical.

    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: Closed - Not Implemented

    Comments: The Departments of Defense (DOD) and Veterans Affairs (VA) have not developed a process for identifying and selecting joint IT investments. DOD and VA senior leaders agreed to develop separate electronic health record solutions that adhere to the same body of technical standards, terminologies, and guidance for interoperability set forth by the Interagency Program Office. Given these commitments, the departments intend for their respective solutions to yield interoperable information exchanges, without the need to identify and select other joint technologies.

    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: Closed - Not Implemented

    Comments: The Department of Defense (DOD) Inspector General, which has responsibility for tracking the department's actions in response to GAO's recommendations, stated that the department did not agree to take any corrective actions on this recommendation. Accordingly, the department did not take steps to strengthen its efforts to establish VLER and the expected IT system capabilities for the FHCC by documenting and approving project plans that included scope definition, as well as estimated costs and schedules.

    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: Closed - Not Implemented

    Comments: The Department of Veterans Affairs (VA) did not stengthen its efforts to establish VLER and the expected IT system capabilities for the FHCC by documenting and approving project plans that included scope definition, as well as estimated costs and schedules.

    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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