VA Has Been Working with DOD to Exchange Health Information for Over a Decade

VA and DOD have been working to exchange patient health data  electronically since 1998. VA has  one integrated medical information system—the Veterans Health  Information Systems and Technology Architecture (VistA)—which  uses all electronic records and was developed in-house by VA  clinicians and IT personnel. VA and DOD Have Increased Information Sharing, but Continue to Face Challenges in Developing and Implementing Interoperable Health Records

VA and DOD have increased their ability to share and use health  information, sharing both computable and viewable data. This  achievement has required years of effort by the two departments,  involving, among other things, agreeing on standards and setting  priorities for the kind of information to be shared and the  appropriate level of interoperability to work toward. Interoperability—the ability to share data among health care  providers—is key to sharing health care information electronically. Interoperability enables different information systems or  components to exchange information and to use the information  that has been exchanged. At the highest  level, electronic data are computable (that is, in a format that a  computer can understand and act on to, for example, provide alerts  to clinicians on drug allergies). As of January  31, 2009, the departments were exchanging computable outpatient  pharmacy and drug allergy data through the CHDR interface on over  27,000 shared patients—an increase of about 9,000 patients since  June 2008. However, the departments have more to do: not all electronic health  information is yet shared. In addition, although VA’s health data are  all captured electronically, information is still captured on paper at  many DOD medical facilities. The involvement of the two departments in these initiatives is  important both because of the experience that the departments can  offer the national effort, and also because their involvement helps  ensure that the standards they adopt are consistent with the  emerging federal standards. VA and DOD Plans Lack Results-Oriented Performance Goals and Measures, and Interagency Program Office Is Not Fully Set Up

Using interoperable health IT to help improve the efficiency and  quality of health care is a complex goal that requires the  involvement of multiple stakeholders in both departments, as well  as numerous activities taking place over an expanse of time. The departments’ efforts to meet the recent  requirements of the National Defense Authorization Act for Fiscal  Year 2008 provide additional examples of such challenges, raising  concerns regarding their ability to most effectively meet the  September 2009 deadline for developing and implementing  interoperable electronic health record systems or capabilities. These plans identify various objectives and activities that, according  to the departments, are aimed at increasing health information  sharing and achieving full interoperability. However, of the 45  objectives and activities identified in their plans, we previously  reported that only 4 were documented with results-oriented (i.e.,  objective, quantifiable, and measurable) performance goals and  measures that are characteristic of effective planning. In neither case are tangible deliverables  described that would permit the departments to determine progress  in achieving these goals. Further, defining results-oriented performance goals and ensuring  that these are met would be an important part of the task of the  program office. Both departments  agreed with our July 2008 recommendation that the departments  give priority to fully establishing the interagency program office. Until the departments complete key activities to set up the program  office, it will not be positioned to be fully functional, or accountable  for fulfilling the departments’ interoperability plans. These include the need to continue to agree on standards for  their own systems while ensuring that they maintain compliance  with federal standards, which are still emerging as part of the effort  to promote the nationwide adoption of health IT. Until  these challenges are addressed, the risk is increased that the  departments will not achieve the ability to share interoperable  electronic health information to the extent and in the manner that  most effectively serves military service members and veterans.
Why GAO Did This Study

For over a decade, the Department of Veterans Affairs (VA) and the Department of Defense (DOD) have been engaged in efforts to improve their ability to share electronic health information. These efforts are vital for making patient information readily available to health care providers in both departments, reducing medical errors, and streamlining administrative functions. In addition, Congress has mandated that VA and DOD jointly develop and implement, by September 30, 2009, electronic health record systems or capabilities that are fully interoperable and compliant with applicable federal interoperability standards. (Interoperability is the ability of two or more systems or components to exchange information and to use the information that has been exchanged.) The experience of VA and DOD in this area is also relevant to broader efforts to advance the nationwide use of health information technology (IT) in both the public and private health care sectors--a goal of both current and past administrations. In this statement, GAO describes VA's and DOD's achievements and challenges in developing interoperable electronic health records, including brief comments on how these apply to the broader national health IT effort.

What GAO Found

Through their long-running electronic health information sharing initiatives, VA and DOD have succeeded in increasing their ability to share and use health information. In particular, they are sharing certain clinical information (pharmacy and drug allergy data) in computable form--that is, in a format that a computer can understand and act on. This permits health information systems to provide alerts to clinicians on drug allergies, an important feature that was given priority by the departments' clinicians. The departments are now exchanging this type of data on over 27,000 shared patients--an increase of about 9,000 patients between June 2008 and January 2009. Sharing computable data is considered the highest level of interoperability, but other levels also have value. That is, data that are only viewable still provide important information to clinicians, and much of the departments' shared information is of this type. However, the departments have more to do: not all electronic health information is yet shared, and although VA's health data are all captured electronically, information is still captured on paper at many DOD medical facilities. To share and use health data has required, among other things, that VA and DOD agree on standards. At the same time, they are participating in federal standards-related initiatives, which is important both because of the experience that the departments bring to the national effort, and also because their involvement helps ensure that their adopted standards are compliant with federal standards. However, these federal standards are still emerging, which could complicate the departments' efforts to maintain compliance. Finally, the departments' efforts face management challenges. Specifically, the effectiveness of the departments' planning for meeting the deadline for fully interoperable electronic health records is reduced because their plans did not consistently identify results-oriented performance goals (i.e., goals that are objective, quantifiable, and measurable) or measures that would permit progress toward the goals to be assessed. Further constraining VA's and DOD's planning effectiveness is their inability to complete all necessary activities to set up the interagency program office, which is intended to be accountable for fulfilling the departments' interoperability plans. Defining goals and ensuring that these are met would be an important part of the task of the program office. Without a fully established office that can manage the effort to meet these goals, the departments increase the risk that they will not be able to share interoperable electronic health information to the extent and in the manner that most effectively serves military service members and veterans. Accordingly, GAO has recommended that the departments give priority to fully establishing the interagency program office and develop results-oriented performance goals and measures to be used as the basis for reporting interoperability progress. The departments concurred with these recommendations.