	Background

DOD operates a worldwide health care program, through which it provides  medical care and assistance to 9.6 million active duty service members,  their families, and other eligible beneficiaries. Block 2 was to provide automated clinical practice guidelines, optometric  documentation, and dental documentation. Speed. Availability. 3. 4. AHLTA Has Limited Capabilities and Continues to Experience Performance Problems

Despite having obligated approximately $2 billion over the 13-year life of  its initiatives to acquire and operate an electronic health record system, as  of September 2010, DOD continued to experience performance problems  with the one block of AHLTA functionality (Block 1) that it had fully  deployed and with a second block of functionality (Block 2) that it had  partially deployed. DOD is proceeding with what it refers to as  a “stabilization effort” to continue making improvements to the system and provide ongoing capabilities until a new system is acquired. DOD Has Initiated Planning Activities for the EHR Way Ahead

Because AHLTA has consistently experienced performance problems and  has not delivered the full operational capabilities intended, DOD has  initiated plans to develop a new electronic health record system. As  with AHLTA, department officials stated that the new electronic health  record system is expected to be a comprehensive, real-time health record  for active and retired service members, their families, and other eligible  beneficiaries. The analysis is currently scheduled to be  completed by December 2010. To facilitate the analysis of alternatives, planning officials stated that they  had identified system capabilities needed to meet the department’s  medical mission. According to planning documents, following completion of the analysis,  DOD expects to select a technical solution and to develop and release a  delivery schedule. DOD’s fiscal year 2011 budget request includes $302 million for the EHR  Way Ahead initiative. AHLTA Performance Was Hindered by Weaknesses in Key Acquisition Management and Planning Processes

The success of a large information technology project such as AHLTA is  dependent on an agency possessing capabilities to effectively plan and  manage acquisitions, design the associated systems, define and manage  system requirements, and use effective measures to gauge user  satisfaction. In the case of AHLTA, weaknesses in these key management  areas contributed to DOD delivering a system that provided fewer  capabilities than originally expected, experienced persistent performance  problems, and ultimately, did not fully meet the needs of its intended  users. Nonetheless, although the program office recognized these types of system  complexities as being part of the electronic health record system design,  the office never established a tailored systems engineering plan to guide  the acquisition, or to facilitate the resolution of the many performance  problems that have plagued the system since its initial deployment. Further, the  system requirements were too general and did not adequately reflect user  needs. Although the department has collected user feedback, it did not  establish a comprehensive plan for improving user satisfaction with the  system. As DOD continues to invest significant resources in a stabilization effort to  address shortcomings of AHLTA and plan for the acquisition of a new  electronic health record system, it is imperative that the department take  immediate steps to improve its management of the initiative. Recommendations for Executive Action

To help guide and ensure the successful completion of the AHLTA  stabilization effort, we recommend that the Secretary of Defense, through  the Assistant Secretary of Defense for Health Affairs, direct the MHS CIO  to take the following six actions:    Develop and maintain a comprehensive project plan that includes key  elements, such as the project’s scope, cost, schedule, and risks and update  the plan to provide key information for stakeholders on the project’s plans  and status. In its  comments, the department agreed with our six recommendations and  described actions planned to address them. Appendix I: Objectives, Scope, and Methodology

Our objectives were to (1) determine the Department of Defense’s (DOD)  status in implementing the Armed Forces Health Longitudinal Technology  Application (AHLTA) system, (2) determine the department’s plans for  acquiring a new electronic health record system, and (3) evaluate the  department’s acquisition management for its electronic health record  system.
Why GAO Did This Study

The Department of Defense (DOD) provides medical care to 9.6 million active duty service members, their families, and other eligible beneficiaries worldwide. DOD's Military Health System has long been engaged in efforts to acquire and deploy an electronic health record system. The latest version of this initiative--the Armed Forces Health Longitudinal Technology Application (AHLTA)--was expected to give health care providers real-time access to individual and military population health information and facilitate clinical support. However, the system's early performance was problematic, and DOD recently stated that it intended to acquire a new electronic health record system. GAO was asked to (1) determine the status of AHLTA, (2) determine DOD's plans for acquiring its new system, and (3) evaluate DOD's acquisition management of the initiative. To do this, GAO reviewed program plans, reports, and other documentation and interviewed DOD officials.

What GAO Found

After obligating approximately $2 billion over the 13-year life of its initiative to acquire an electronic health record system, as of September 2010, DOD had delivered various capabilities for outpatient care and dental care documentation. DOD had scaled back other capabilities it had originally planned to deliver, such as replacement of legacy systems and inpatient care management. In addition, users continued to experience significant problems with the performance (speed, usability, and availability) of the portions of the system that have been deployed. DOD has initiated efforts to improve system performance and enhance functionality and plans to continue its efforts to stabilize the AHLTA system through 2015, as a "bridge" to the new electronic health record system it intends to acquire. According to DOD, the planned new electronic health record system--known as the EHR Way Ahead--is to be a comprehensive, real-time health record for service members and their families and beneficiaries. The system is expected to address performance problems, provide unaddressed capabilities such as comprehensive medical documentation, capture and share medical data electronically within DOD, and improve existing information sharing with the Department of Veterans Affairs. As of September 2010, the department had established a planning office, and this office had begun an analysis of alternatives for meeting the new system requirements. Completion of this analysis is currently scheduled for December 2010. Following its completion, DOD expects to select a technical solution for the system and release a delivery schedule. DOD's fiscal year 2011 budget request included $302 million for the EHR Way Ahead initiative. Weaknesses in key acquisition management and planning processes contributed to AHLTA having fewer capabilities than originally expected, experiencing persistent performance problems, and not fully meeting the needs of users. (1) A comprehensive project management plan was not established to guide the department's execution of the system acquisition. (2) A tailored systems engineering plan did not exist to guide the technical development of the system, an effort that was characterized by significant complexity. (3) Requirements were incomplete and did not sufficiently reflect user and operational needs. (4) An effective plan was not used to improve users' satisfaction with the system. DOD has initiated efforts to bring its processes into alignment with industry best practices. However, it has not carried out a planned independent evaluation to ensure it has made these improvements. Until it ensures that these weaknesses are addressed, DOD risks undermining the success of further efforts to acquire electronic health record system capabilities.

What GAO Recommends

GAO is recommending that DOD take six actions to help ensure that it has disciplined and effective processes in place to manage the acquisition of further electronic health record system capabilities. In written comments on a draft of this report, DOD concurred with GAO's recommendations and described actions planned to address them.