	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. 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. Although they have identified many common health care business needs,  both departments have spent large sums of money to develop and  operate separate electronic health record systems that they rely on to  create and manage patient health information. These have included efforts to: share viewable  data in existing (legacy) systems; link and share computable data  between the departments’ modernized health data repositories; establish  interoperability objectives to meet specific data-sharing needs; develop a  virtual lifetime electronic health record to track patients through active  service and veteran status; and implement IT capabilities for the first joint  federal health care center. The department subsequently  revised the strategy for GCPR and, in May 2002, narrowed the scope of  the initiative to focus on enabling DOD to electronically transfer service  members’ electronic health information to VA upon their separation from  active duty. Further, in March 2004, the departments began an effort to develop an  interface linking VA’s Health Data Repository and DOD’s Clinical Data  Repository, as part of a long-term initiative to achieve the two-way  exchange of health information between the departments’ modernized  systems—known as CHDR. In September 2005, we testified that the departments had improved the  management of the CHDR program, but that this program continued to  face significant challenges—in particular, with developing a project  management plan of sufficient specificity to be an effective guide for the  program. Efforts to Comply with 2008 Mandate to Achieve Fully Interoperable Health Records Capabilities Lacked Project Plans and Measures of Effectiveness

To increase the exchange of electronic health information between the  two departments, the National Defense Authorization Act (NDAA) for  Fiscal Year 2008 included provisions directing VA and DOD to jointly  develop and implement, by September 30, 2009, fully interoperable  electronic health record systems or capabilities. Even with these actions, however, we identified a number of challenges  the departments faced in managing their efforts in response to the 2008  NDAA. Accordingly, we recommended that DOD and VA take  action to develop such goals and performance measures to be used as a  basis for providing meaningful information on the status of the  departments’ interoperability initiatives. In July 2009, we reported that the IPO had not fulfilled key management  responsibilities identified in its charter, such as the development of an  integrated master schedule and a project plan for the department’s efforts  to achieve full interoperability. VLER is  intended to enable access to all electronic records for service members  as they transition from military to veteran status, and throughout their  lives. However, in a February 2011 report on the departments’ efforts to  address their common health IT needs, we noted that although VA and  DOD identified a high-level approach for implementing VLER and  designated the IPO as the single point of accountability for the effort, they  had not developed a comprehensive plan identifying the target set of  capabilities that they intended to demonstrate in the pilot projects and  then implement on a nationwide basis at all domestic VA and DOD sites  by the end of 2012. Among other things, the Executive  Agreement specified three key IT capabilities that VA and DOD were  required to have in place by the FHCC’s opening day, in October 2010, to  facilitate interoperability of their electronic health record systems:    medical single sign-on, which would allow staff to use one screen to  access both the VA and DOD electronic health record systems;    single patient registration, which would allow staff to register  patients in both systems simultaneously; and    orders portability, which would allow VA and DOD clinicians to  place, manage, and update clinical orders from either department’s  electronic health records systems for radiology, laboratory, consults  (specialty referrals), and pharmacy services. VA and DOD Recently Changed Their Approach to Developing an Integrated Electronic Health Record

Beyond the aforementioned initiatives, in March 2011 the Secretaries of  VA and DOD committed the two departments to developing a new  common integrated electronic health record (iEHR), and in May 2012  announced their goal of implementing it across the departments by 2017. In  addition, because it would involve both departments using the same  system, this approach would largely sidestep the challenges they have  encountered in trying to achieve interoperability between separate  systems. The Secretaries offered  several reasons for this new direction, including cutting costs, simplifying  the problem of integrating VA and DOD health data, and meeting the  needs of veterans and service members sooner rather than later. In summary, while VA and DOD have made progress in increasing  interoperability between their health information systems over the past 15  years, these efforts have faced longstanding challenges.
Why GAO Did This Study

VA and DOD operate two of the nation's largest health care systems-- systems that serve populations of veterans and active service members and their dependents. To better serve these populations, VA and DOD have been collaborating for about 15 years on a variety of initiatives to share data among the departments' health information systems. The use of IT to electronically collect, store, retrieve, and transfer such data has the potential to improve the quality and efficiency of health care. Particularly important in this regard is developing electronic health records that can be accessed throughout a patient's military and veteran status. Making such information electronic can ensure greater availability of health care information for service members and veterans at the time and place of care. Although they share many common business needs, both VA and DOD have spent large sums of money to develop and maintain separate electronic health record systems that they use to create and manage patient health information.
GAO was asked to testify on (1) the departments' efforts, and challenges faced, in electronically sharing health information and (2) the recent change in their approach to developing an integrated electronic health record. In preparing this statement, GAO relied primarily on previously published work in this area.

What GAO Found

The Departments of Veterans Affairs (VA) and Defense (DOD) have undertaken a number of patchwork efforts over the past 15 years to achieve interoperability (i.e., the ability to share data) of records between their information systems; however, these efforts have faced persistent challenges. The departments' early efforts to achieve interoperability included enabling DOD to electronically transfer service members' electronic health information to VA; allowing clinicians at both departments viewable access to records on shared patients; and developing an interface linking the departments' health data repositories. As GAO reported, however, several of these efforts were plagued by project planning and management weaknesses, inadequate accountability, and poor oversight, limiting their ability to realize full interoperability.
To further expedite data sharing, the National Defense Authorization Act of 2008 directed VA and DOD to jointly develop and implement fully interoperable electronic health record capabilities by September 30, 2009. The departments asserted that they met this goal, though they planned additional work to address clinicians' evolving needs. GAO identified weaknesses in the departments' management of these initiatives, such as a lack of defined performance goals and measures that would provide a comprehensive picture for managing progress. In addition, the departments' Interagency Program Office, which was established to be a single point of accountability for electronic health data sharing, had not fulfilled key management responsibilities.
In 2009, the departments began work on the Virtual Lifetime Electronic Record initiative to enable access to all electronic records for service members transitioning from military to veteran status, and throughout their lives. To carry this out, the departments initiated several pilot programs but had not defined a comprehensive plan that defined the full scope of the effort or its projected cost and schedule. Further, in 2010, VA and DOD established a joint medical facility that was, among other things, to have certain information technology (IT) capabilities to facilitate interoperability of the departments' electronic health record systems. Deployment of these capabilities was delayed, however, and some have yet to be implemented.
In 2011, the VA and DOD Secretaries committed to developing a new common integrated electronic health record system, with a goal of implementing it across the departments by 2017. This approach would largely sidestep the challenges in trying to achieve interoperability between separate systems. However, in February 2013, the Secretaries announced that the departments would focus on modernizing their existing systems, rather than developing a single system. They cited cost savings and meeting needs sooner rather than later as reasons for this decision. Given the long history of challenges in achieving interoperability, this reversal of course raises concerns about the departments' ability to successfully collaborate to share electronic health information. Moreover, GAO has identified barriers to the departments jointly addressing their common needs arising from deficiencies in key IT management areas, which could continue to jeopardize their pursuits. GAO is monitoring the departments' progress in overcoming these barriers and has additional ongoing work to evaluate their activities to develop integrated electronic health record capabilities.

What GAO Recommends

Since 2001, GAO has made numerous recommendations to improve VA's and DOD's management of their efforts to share health information.