	Background

VA operates one of the largest health care systems in America, providing  care to millions of veterans and their families each year. Since 1998, VA has undertaken a patchwork of initiatives with DOD to  allow the departments’ health information systems to exchange  information and increase interoperability. Table 1  summarizes a number of these key initiatives. Together with DOD and the Interagency Program Office, VA Needs to Develop Goals and Metrics for Assessing Interoperability

Even as VA has undertaken numerous initiatives with DOD that were  intended to advance electronic health record interoperability, a significant  concern is that these departments have not identified outcome-oriented  goals and metrics to clearly define what they aim to achieve from their  interoperability efforts, and the value and benefits these efforts are  expected to yield. The IPO is responsible for monitoring and reporting on VA’s and DOD’s  progress in achieving interoperability and coordinating with the  departments to ensure that these efforts enhance health care services. Accordingly, we recommended that the departments,  working with the IPO, establish a time frame for identifying outcome- oriented metrics; define related goals as a basis for determining the  extent to which the departments’ modernized electronic health record  systems are achieving interoperability; and update IPO guidance  accordingly. Further, since  that time, VA has established a performance architecture program that  has begun to define an approach for identifying outcome-oriented metrics  focused on health outcomes in selected clinical areas, and it also has  begun to establish baseline measurements. We intend to continue  monitoring the department’s efforts to determine how these metrics define  and report on the results achieved by interoperability between the  departments. VA’s Plan to Modernize VistA Raises Concern about Duplication with DOD’s Electronic Health Record System Acquisition

Following the termination of the iEHR initiative, VA moved forward with an  effort to modernize VistA separately from DOD’s planned acquisition of a  commercially available electronic health record system. The department  took this course of action even though it has many health care business  needs in common with those of DOD. Further, the results of a  2008 study pointed out that over 97 percent of inpatient requirements for  electronic health record systems are common to both departments. Moreover, we noted that the  departments’ plans to modernize their two separate systems were  duplicative and stressed that their decisions should be justified by  comparing the costs and schedules of alternate approaches. VA, as well as DOD, agreed with our recommendations and stated that  an initial comparison had indicated that the approach involving separate  systems would be more cost effective. However, as of June 2016, the  departments had not provided us with a comparison of the estimated  costs of their current and previous approaches. Further, with respect to  their assertions that separate systems could be achieved faster, both  departments had developed schedules which indicated that their separate  modernization efforts are not expected to be completed until after the  2017 planned completion date for the previous single-system approach. These include an interoperability plan and a road map  describing functional capabilities to be deployed through fiscal year 2018. According to  the road map, the first set of capabilities was delivered by the end of  September 2014 and included access to the Joint Legacy Viewer and a  foundation for future functionality, such as an enhanced graphical user  interface and enterprise messaging infrastructure. However, a recent independent assessment of health IT at VA reported  that lengthy delays in modernizing VistA had resulted in the system  becoming outdated. Further, this study questioned whether the VistA  Evolution program to modernize the electronic health record system can  overcome a variety of risks and technical issues that have plagued prior  VA initiatives of similar size and complexity. In speaking about this matter, VA’s Under Secretary for Health has  asserted that the department will follow through on its plans to complete  the VistA Evolution program in fiscal year 2018. However, the Chief  Information Officer has also indicated that the department is taking a step  back in reconsidering how best to meet its electronic health record  system needs beyond fiscal year 2018. As such, VA’s approach to  addressing its electronic health record system needs remains uncertain.
Why GAO Did This Study

VA operates one of the nation's largest health care systems, serving millions of veterans each year. For almost two decades, the department has undertaken a patchwork of initiatives with DOD to increase interoperability between their respective electronic health record systems. During much of this time, VA has also been planning to modernize its system. While the department has made progress in these efforts, it has also faced significant information technology challenges that contributed to GAO's designation of VA health care as a high risk area.
This statement summarizes GAO's August 2015 report (GAO-15-530) on VA's efforts to achieve interoperability with DOD's electronic health records system. It also summarizes key content from GAO's reports on duplication, overlap, and fragmentation of federal government programs. Lastly, this statement provides updated information on VA's actions in response to GAO's recommendation calling for an interoperability and electronic health record system plan.

What GAO Found

Even as the Department of Veterans Affairs (VA) has undertaken numerous initiatives with the Department of Defense (DOD) that were intended to advance the ability of the two departments to share electronic health records, the departments have not identified outcome-oriented goals and metrics to clearly define what they aim to achieve from their interoperability efforts. In an August 2015 report, GAO recommended that the two departments establish a time frame for identifying outcome-oriented metrics, define related goals as a basis for determining the extent to which the departments' systems are achieving interoperability, and update their guidance accordingly. Since that time, VA has established a performance architecture program that has begun to define an approach for identifying outcome-oriented metrics focused on health outcomes in selected clinical areas and has begun to establish baseline measurements. GAO is continuing to monitor VA's and DOD's efforts to define metrics and report on the interoperability results achieved between the departments.
Following an unsuccessful attempt to develop a joint system with DOD, VA switched tactics and moved forward with an effort to modernize its current system separately from DOD's planned acquisition of a commercially available electronic health record system. The department took this course of action even though, in May 2010, it identified 10 areas of health care business needs in common with those of DOD. Further, the results of a 2008 study pointed out that more than 97 percent of inpatient requirements for electronic health record systems are common to both departments. GAO noted that the departments' plans to separately modernize their systems were duplicative and recommended that their decisions should be justified by comparing the costs and schedules of alternate approaches. The departments agreed with GAO's recommendations and stated that their initial comparison indicated that separate systems would be more cost effective. However, the departments have not provided a comparison of the estimated costs of their current and previous approaches. Further, both departments developed schedules that indicated their separate modernization efforts will not be completed until after the 2017 planned completion date for the previous joint system approach.
VA has developed a number of plans to support its development of its electronic health record system, called VistA, including a plan for interoperability and a road map describing functional capabilities to be deployed through fiscal year 2018. According to the road map, the first set of capabilities was delivered by the end of September 2014 and included a foundation for future functionality, such as an enhanced graphical user interface and enterprise messaging infrastructure. However, a recent independent assessment of health information technology (IT) at VA reported that lengthy delays in modernizing VistA had resulted in the system becoming outdated. Further, this study questioned whether the modernization program can overcome a variety of risks and technical issues that have plagued prior VA initiatives of similar size and complexity. Although VA's Under Secretary for Health has asserted that the department will complete the VistA Evolution program in fiscal year 2018, the Chief Information Officer has indicated that the department is reconsidering how best to meet its future electronic health record system needs.

What GAO Recommends

In prior reports, GAO has made numerous recommendations to VA to improve the modernization of its IT systems. Among other things, GAO has recommended that VA address challenges associated with interoperability, develop goals and metrics to determine the extent to which the modernized systems are achieving interoperability, and address shortcomings with planning. VA generally agreed with GAO's recommendations.