VA and DOD Abandoned Plans for a Single System, but Their New Approach to Achieving an Interoperable Electronic Health Record Is Not Supported by Sufficient Cost and Schedule Analysis or a Complete Plan

About 2 years after taking actions toward the development of iEHR, VA  and DOD announced changes to their plan—essentially abandoning their  effort to develop a single, integrated electronic health record system for  both departments. The Departments Abandoned Plans for a Single System in Favor of Separate Modernization Efforts

In February 2013, the Secretaries of Defense and Veterans Affairs  announced that they would not continue with their joint development of a  single electronic health record system that was intended to result in an  integrated electronic health record. In particular, major investment decisions (which can  include, for example, terminating or significantly restructuring an ongoing  program) should be justified using analyses that compare relative costs  and schedules for proposed investments. Until VA and DOD provide a plan that  reflects their current approach, the departments and their stakeholders  may not have a shared understanding of how they intend to address their  common health care business needs, including an interoperable  electronic health record, going forward. Collaboration between VA and DOD Has Been Hindered by Long-standing Barriers and Ineffective Implementation of the IPO

We have previously reported on IT management barriers that prevented  the departments from effectively collaborating to address their common  health care system needs in the areas of enterprise architecture and IT  investment management. In addition, the Interagency Program Office, established by the fiscal year  2008 NDAA to act as a single point of accountability for the departments’  development and implementation of interoperable health records, was to  better position the departments to collaborate. Specifically, the departments  did not provide the IPO with authority over essential resources or with the  autonomy to establish key interagency processes for managing joint  activities. For example, VA and DOD have not further developed a joint health  architecture that could guide their efforts to address their common health  care business needs, as we recommended. The IPO was to better position the departments to collaborate on  joint health IT initiatives. However,  in addition to reducing the IPO’s role, responsibilities, and authority over  these efforts in its 2013 charter, the departments have identified other  offices to execute health data interoperability initiatives formerly managed  by the IPO. However, the  departments’ assertion is questionable because they have not developed  cost and schedule estimates to substantiate their claim or justify their  decision. In the absence of credible analyses to guide decisions about  how to cost-effectively and expeditiously develop the interoperable  electronic health record needed to provide service members and veterans  with the best possible care, VA and DOD have fallen back on the  divergent approaches that each department has determined to be best for  it—VA intends to modernize VistA, and DOD expects to acquire a new  commercially available system. While the departments have begun  planning for these separate systems, they have yet to develop plans  describing what a future interoperable health record will consist of or how,  when, and at what cost it will be achieved. Recommendations for Executive Action

To bring transparency and credibility to the Secretaries of Veterans  Affairs and Defense’s assertion that VA and DOD’s current approach to  achieving an interoperable electronic health record will cost less and take  less time than the previous single-system approach, we recommend that  the secretaries develop a cost and schedule estimate for their current approach, from  the perspective of both departments, that includes the estimated cost  and schedule of VA’s VistA Evolution program, DOD’s DHMSM  program, and the departments’ joint efforts to achieve interoperability  between the two systems; then,  compare the cost and schedule estimates of the departments’ current  and previous (i.e., single-system) approaches. To better position the Interagency Program Office for effective  collaboration between VA and DOD and to efficiently and effectively fulfill  the office’s stated purpose of functioning as the single point of  accountability for achieving interoperability between the departments’  electronic health record systems, we recommend that the Secretaries of  Veterans Affairs and Defense ensure that the IPO has authority over dedicated resources (e.g., budget and staff), to develop interagency processes, and  to make decisions over the departments’ interoperability efforts. Appendix I: Objectives, Scope, and Methodology

The objectives of this study were to (1) describe changes the Department  of Defense (DOD) and Department of Veterans Affairs (VA) have made to  the Integrated Electronic Health Record (iEHR) program since its  inception, and evaluate the departments’ current plans for the program  and (2) determine whether the departments, including the DOD/VA  Interagency Program Office (IPO), are effectively collaborating on  management of the iEHR program.
Why GAO Did This Study

VA and DOD operate two of the nation's largest health care systems, serving approximately 16 million veterans and active duty service members, and their beneficiaries, at total annual costs of over $100 billion. The departments have recognized the importance of developing capabilities for sharing electronic patient health information and have worked since 1998 to develop such capabilities. In February 2011, VA and DOD initiated a program to develop a single, common electronic health record system—iEHR—to replace their existing health record systems. This program was to be managed by the IPO and implemented by 2017. However, the departments made significant changes to the program in 2013. GAO was asked to review the iEHR program. This report (1) describes changes to the program and evaluates the departments' current plans and (2) determines whether the departments are effectively collaborating on management of the program. GAO reviewed relevant program documents and interviewed agency officials.

What GAO Found

The Departments of Veterans Affairs (VA) and Defense (DOD) abandoned their plans to develop an integrated electronic health record (iEHR) system and are instead pursuing separate efforts to modernize or replace their existing systems in an attempt to create an interoperable electronic health record. Specifically, in February 2013, the secretaries cited challenges in the cost and schedule for developing the single, integrated system and announced that each department would focus instead on either building or acquiring similar core sets of electronic health record capabilities, then ensuring interoperability between them. However, VA and DOD have not substantiated their claims that the current approach will be less expensive and more timely than the single-system approach. Major investment decisions—including terminating or significantly restructuring an ongoing program—should be justified using analyses that compare the costs and schedules of alternative proposals. Yet, the departments have not developed revised cost and schedule estimates for their new modernization efforts and any additional efforts needed to achieve interoperability between the new systems, and compared them with the relevant estimates for their former approach. In the absence of such a comparison, VA and DOD lack assurance that they are pursuing the most cost-effective and timely course of action for delivering the fully interoperable electronic health record the departments have long pursued to provide the best possible care for service members and veterans.
The departments have initiated their separate system efforts. VA intends to deploy clinical capabilities of its new system at two locations by September 2014, and DOD has set a goal of beginning deployment of its new system by the end of fiscal year 2016. However, the departments have yet to update their joint strategic plan to reflect the new approach or to disclose what the interoperable electronic health record will consist of, as well as how, when, and at what cost it will be achieved. Without plans that include the scope, lines of responsibility, resource requirements, and an estimated schedule for achieving an interoperable health record, VA, DOD, and their stakeholders may not have a shared understanding of how the departments intend to address their common health care business needs.
VA and DOD have not addressed management barriers to effective collaboration on their joint health information technology (IT) efforts. As GAO previously reported, the departments faced barriers to effective collaboration in the areas of enterprise architecture and IT investment management, among others. However, they have yet to address these barriers by, for example, developing a joint health care architecture or a joint IT investment management process to guide their collaboration. Further, the Interagency Program Office (IPO), established by law to act as a single point of accountability for the departments' development of interoperable health records, was to better position the departments to collaborate; but the departments have not implemented the IPO in a manner consistent with effective collaboration. For example, the IPO lacks effective control over essential resources such as funding and staffing. In addition, recent decisions by the departments have diffused responsibility for achieving integrated health records, potentially undermining the IPO's intended role as the point of accountability. Providing the IPO with control over essential resources and clearer lines of authority would better position it for effective collaboration.

What GAO Recommends

GAO recommends that VA and DOD develop and compare the estimated cost and schedule of their current and previous approaches to creating an interoperable electronic health record and, if applicable, provide a rationale for pursuing a more costly or time-consuming approach. GAO also recommends that the departments develop plans for interoperability and ensure the IPO has control over needed resources and clearer lines of authority. VA and DOD concurred with GAO's recommendations.