Departments of Defense and Veterans Affairs: Status of the Integrated Electronic Health Record (iEHR)
The purpose of this report is to provide a background on the long-standing efforts in sharing health information between Department of Defense (DOD) and the Department of Veterans Affairs (VA).
Departments of Defense and Veterans Affairs:
Status of the Integrated Electronic Health
Record (iEHR)
Sidath Viranga Panangala
Specialist in Veterans Policy
Don J. Jansen
Analyst in Defense Health Care Policy
February 26, 2013
Congressional Research Service
7-5700
www.crs.gov
R42970
CRS Report for Congress
Pr
epared for Members and Committees of Congress
Departments of Defense and Veterans Affairs: Status of the iEHR
Summary
Electronic health records (EHRs) play an important role in optimizing the health care provided to
active duty servicemembers and veterans. When a servicemember leaves military service by way
of discharge, separation, or retirement he or she may become eligible for VA benefits and services
including VA health care. Transitioning their health care information from one large health care
system (Department of Defense; DOD) to the other (Department of Veterans Affairs; VA)
involves coordination of data and information between DOD and VA. Longstanding concern that
this exchange be effective has been expressed in many quarters, including Congress.
The DOD and the VA have been working to exchange patient health information since 1998. To
date, both Departments’ initiatives include (1) the Federal Health Information Exchange (FHIE),
which enables the one-way transfer of servicemembers’ electronic health information from DOD
to VA for all separated servicemembers; (2) the Bidirectional Health Information Exchange
(BHIE), which allows health care providers from both Departments viewable access to records of
shared patients; (3) the Clinical Data Repository/Veterans Affairs Health Data Repository
(CHDR),which enables the DOD and VA to exchange computable outpatient pharmacy and drug
allergy information for shared patients; and (4) the Laboratory Data Sharing Interphase (LDSI),
which allows DOD and VA facilities to share laboratory information.
Congressional committees with oversight over veterans matters have devoted attention to health
information sharing between the DOD and VA. In 2008, they included relevant provisions in the
National Defense Authorization Act for FY2008 (P.L. 110-181). The law mandated DOD and VA
to jointly develop and implement electronic health record systems or capabilities to allow for full
interoperability of personal health care information, and to accelerate the exchange of health care
information between DOD and VA by September 2009. To this end, the law also established an
interagency program office (IPO) to act as a single point of accountability.
In December 2010, the Deputy Secretaries of DOD and VA directed the development of an
integrated Electronic Health Record (iEHR), which would provide both Departments an
opportunity to reduce costs and improve interoperability and connectivity. On March 17, 2011,
the Secretaries of DOD and VA reached an agreement to work cooperatively on the development
of a common electronic health record and to transition to the new iEHR by 2017.
On February 5, 2013, the Secretary of Defense and the Secretary of Veterans Affairs announced
that instead of building a single integrated electronic health record (iEHR), both DOD and VA
will concentrate on integrating VA and DOD health data by focusing on interoperability and using
existing technological solutions. This announcement was a departure from the previous
commitments that both Departments had made to design and build a new single iEHR, rather than
upgrading their current electronic health records and trying to develop interoperability solutions.
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Departments of Defense and Veterans Affairs: Status of the iEHR
Contents
Introduction ...................................................................................................................................... 1
Methodology and Limitation ..................................................................................................... 2
Background ...................................................................................................................................... 2
Electronic Health Records in the Context of Servicemembers and Veterans ............................ 3
VA and DOD Health Record Systems Interoperability .................................................................... 4
DOD-VA Electronic Health Records Sharing Efforts: 1998-2008 ............................................ 6
Congressional Mandates ............................................................................................................ 9
GAO Reports ..................................................................................................................... 10
Current Status ................................................................................................................................ 11
Interagency Program Office (IPO) .......................................................................................... 11
Initial Interoperability Goals ................................................................................................... 11
DOD-VA iEHR ........................................................................................................................ 12
February 2013 Announcement................................................................................................. 13
Concluding Observations ............................................................................................................... 13
Figures
Figure 1. Current State of DOD-VA EHR Systems ......................................................................... 8
Figure D-1. Selected DOD and VA Health Records Development and Sharing Efforts ............... 27
Tables
Table 1. DOD-VA Clinical Data Sharing Initiatives ........................................................................ 7
Table A-1. List of Acronyms .......................................................................................................... 14
Table C-1. GAO Reports/Testimony on VA and DOD Sharing of Patient
Health Information ..................................................................................................................... 17
Appendixes
Appendix A. Acronyms.................................................................................................................. 14
Appendix B. Selected Congressional Hearings, 2000-2011 .......................................................... 15
Appendix C. GAO Reports/Testimony on VA and DOD Sharing of Patient Health
Information ................................................................................................................................. 17
Appendix D. Milestones of Selected DOD and VA Health Records Development and
Sharing Efforts ............................................................................................................................ 27
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Departments of Defense and Veterans Affairs: Status of the iEHR
Contacts
Author Contact Information........................................................................................................... 29
Acknowledgments ......................................................................................................................... 29
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Departments of Defense and Veterans Affairs: Status of the iEHR
Introduction
On February 5, 2013, Secretary of Defense Leon E. Panetta and Secretary of Veterans Affairs Eric
Shinseki announced that instead of building a single integrated electronic health record (iEHR)—
that both the Department of Defense (DOD) and the Department of Veterans Affairs (VA) would
use for their beneficiaries—their Departments would concentrate on integrating VA and DOD
health data by focusing on interoperability and using existing technological solutions.1 This
announcement appears to be a departure from the previous commitment that both Departments
had made to design and build a new iEHR, rather than upgrading their current electronic health
records and trying to develop interoperability solutions.2 For example, at a joint hearing of the
House Veterans’ Affairs and Armed Services Committees on July 25, 2012, Secretary Shinseki
stated:
Secretary Panetta and I have committed to developing a single, common, joint electronic
health record, known as iEHR. This effort began on January 21, 2009, when then-Secretary
Gates and I agreed to develop that vision. Last year [2011], after two years of hard work by
teams from both Departments, then-Secretary Gates and I met on 5 February, 17 March, 2
May, and 23 June. Thereafter, Secretary Panetta and I met on five additional occasions to
provide continuing guidance and energy for the implementation of the iEHR. It will unify the
two Departments’ electronic health record systems into a common system to ensure that all
DOD and VA health facilities have servicemembers’ and veterans’ health information
available throughout their lifetimes.3
At the same hearing Secretary Panetta stated:
When operational, the integrated electronic health record will be the single source for
servicemembers and veterans to access their medical history at any DOD and VA medical
facility. It will help ensure they get the best care possible. It will also be the world’s largest
health record system, and that could mean that other federal and commercial health care
providers may adopt our protocols, which will expand the capabilities of the system still
further.4
This development is one of several changes in goals, initiatives, and deadlines in the DOD and
VA effort to develop a single integrated electronic medical record since 1998 (see Figure D-1).
1 U.S. Department of Defense, “Remarks by Secretary Panetta and Secretary Shinseki from the Department of Veterans
Affairs,” press release, February 5, 2013, http://www.defense.gov/Transcripts/Transcript.aspx?TranscriptID=5187
(accessed February 16, 2013).
2 Institute of Medicine (IOM), Evaluation of the Lovell Federal Health Care Center Merger: Findings, Conclusions,
and Recommendations, Washington, DC, 2012, p.S-12.
3 Statement of the Hon. Eric K. Shinseki, Secretary of Veterans Affairs, before the House Committee on Veterans’
Affairs and the House Committee on Armed Services, July 25, 2012, http://armedservices.house.gov/index.cfm/2012/7/
back-from-the-battlefield-dod-and-va-collaboration-to-assist-service-members-returning-to-civilian-life (accessed
February 16, 2013).
4 Statement of the Hon. Leon E. Panetta, Secretary of Defense, before the House Committee on Veterans’ Affairs and
the House Committee on Armed Services, July 25, 2012, http://armedservices.house.gov/index.cfm/2012/7/back-from-
the-battlefield-dod-and-va-collaboration-to-assist-service-members-returning-to-civilian-life (accessed February 16,
2013).
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The rest of this report is organized into three parts. It begins with a brief discussion of electronic
health records and their use in health care in general, and in the context of servicemembers and
veterans. The second part of the report discusses DOD and VA health records sharing efforts
including congressional efforts at encouraging health information sharing between the DOD and
the VA. The report concludes with a discussion of the current status of the iEHR initiative. The
purpose of this report is to provide a background on the long-standing efforts in sharing health
information between DOD and VA. It does not discuss long-term implications of the most recent
decision.
Methodology and Limitation
To trace the evolution of DOD and VA efforts to share medical information, CRS examined and
reviewed numerous taskforce and commission reports; Government Accountability Office (GAO)
reports; peer reviewed journal articles; and congressional hearings that addressed health
information sharing between DOD and VA. Additionally, to understand iEHR activities (prior to
the February 5 announcement by Secretary Panetta and Secretary Shinseki) CRS spoke with
officials of the Interagency Program Office (IPO).5 A technical discussion of the iEHR and the
cost of developing and deploying it are beyond the scope of this report.
A list of acronyms used throughout this report is provided in Table A-1.
Background
Traditionally the health information of a patient seeking treatment has been recorded on paper,
maintained by individual physicians, and located in multiple sites, making it a challenge to access
all the vital health information at the time the patient seeks care.6 According to the Institute of
Medicine (IOM), the success of any health care system does not rely solely on its physical
infrastructure and the health care professionals but also on how it collects, maintains, and
processes patient health information.7 Recent research studies and health policy debates have
highlighted the potential value of electronic health records (EHR; see text box below).8
Furthermore, studies have shown that the adoption of EHRs has the potential to improve quality
and efficiency of patient care.9,10,11
5 Congressional Research Service (CRS) met with staff from the Interagency Program Office (IPO), on December 17,
2012.
6 Stephen P. Hufnagel, “National Electronic Health Record Interoperability Chronology,” Military Medicine, vol. 174,
no. 5 (May 2009), p. 35.
7 Institute of Medicine (IOM), Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment
Needs of Veterans, Service Members, and Their Families, Washington, DC, 2010, p. 120.
8 Laura Bonner et al., “To Take Care of Patients’: Qualitative Analysis of Veterans Health Administration Personnel
Experiences with a Clinical Informatics System,” Implementation Science, vol. 5, no. 63 (2010), p. 1.
9 Melinda Beeuwkes Buntin et al., “The Benefits of Health Information Technology: A Review of the Recent Literature
Shows Predominantly Positive Results,” Health Affairs, vol. 30, no. 3 (March 2011), p. 469.
10 Ashish K. Jha, “The Promise of Electronic Records: Around the Corner or Down the Road?,” JAMA, vol. 306, no. 8
(August 24, 2011), p. 880.
11 Colene M. Byne et al., “The Value From Investments in Health Information Technology at The U.S. Department of
Veterans Affairs,” Health Affairs, vol. 29, no. 4 (April 2010), p. 634.
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What Is an Electronic Health Record (EHR)?
Although the definition of EHRs can vary substantial y, there are general y four core components of an EHR:
electronic clinical documentation (usually physician, nurse, and other clinician documentation), electronic prescribing
(e.g., computerized provider order entry), results reporting and management (e.g., clinical data repository), and
clinical decision support. Many EHRs also include barcoding systems and patient engagement tools. The Office of the
National Coordinator for Health Information Technology (ONC) defines an EHR as “a real-time patient health record
with access to evidence-based decision support tools that can be used to aid clinicians in decision-making. The EHR
can automate and streamline a clinician’s workflow, ensuring that all clinical information is communicated. It can also
prevent delays in response that result in gaps in care. The EHR can also support the collection of data for uses other
than clinical care, such as billing, quality management, outcome reporting, and public health disease surveillance and
reporting.”
Source: Institute of Medicine, Health IT and Patient Safety: Building Safer Systems for Better Care, Washington, DC,
2012, p. 38.
However, studies have shown that, to date, efforts to implement EHR systems have yielded mixed
results in terms of quality and safety of health care.12 Recently, an IOM report made
recommendations emphasizing that health information technology (HIT) should be developed and
implemented with safety as a primary focus.13 According to this report, “designed and applied
inappropriately, health IT can add an additional layer of complexity to the already complex
delivery of health care, which can lead to unintended adverse consequences, for example dosing
errors, failing to detect fatal illnesses, and delaying treatment due to poor human–computer
interactions or loss of data.”14
Electronic Health Records in the Context of Servicemembers
and Veterans
Each year more than 150,000 servicemembers separate from military service and transition to
veteran status. Transitioning their health care information from one large health care system
(DOD) to the other (VA) involves coordination of data and information between DOD and VA.15
Additionally, for those who are injured in combat operations, the treatment path stretches from
the battlefield to inpatient/outpatient care in the U.S. to servicemembers’ transition back into
military duty and/or civilian life.16 Medical information is captured during each of these phases.
Because of incompatibility between the DOD and VA systems, when servicemembers separate
from the military and enter VA, their DOD health records do not transfer to VA providers.17 As
stated by the President’s Commission on Care for America’s Returning Wounded Warriors (also
12 Arthur L. Kellermann and Spencer S. Jones, “What It Will Take to Achieve The As-Yet-Unfulfilled Promises of
Health Information Technology,” Health Affairs, vol. 32, no. 1 (January 2013), p. 63.
13 National Academy of Sciences, Institute of Medicine, Health IT and Patient Safety: Building Safer Systems for
Better Care, November 8, 2011, pp. S-1, http://www.iom.edu/Reports/2011/Health-IT-and-Patient-Safety-Building-
Safer-Systems-for-Better-Care (accessed February 19, 2013).
14 Ibid, p. S-2.
15 VA/DOD Joint Executive Council, VA/DOD Joint Executive Council Annual Report, FY 2011 Annual Report,
Washington, DC, p. 70.
16 President’s Commission on Care for America’s Returning Wounded Warriors, Serve, Support, Simplify, Report of
the President’s Commission on Care for America’s Returning Wounded Warriors, July 2007, p. 117.
17 Institute of Medicine (IOM), Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment
Needs of Veterans, Service Members, and Their Families, Washington, DC, 2010, p. 122.
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known as the Dole-Shalala Commission), “integration of the health information systems [is]
necessary to make information available for the comprehensive care and recovery planning
needed to return injured servicemembers to the fullest possible state of health.”18 The IOM, which
was tasked with studying the readjustment needs of veterans, servicemembers and their families
by Congress,19 found that “the lack of unified electronic medical records in DOD has impeded
record-sharing with VA.”20 Additionally, once a veteran files a claim for disability benefits,21 the
VA has a “duty to assist” the claimant by obtaining medical records that a claimant has identified
and authorized the VA to obtain.22 These medical records may include information from both
DOD and VA.23
VA and DOD Health Record Systems
Interoperability
The challenge faced in responding to veterans’ health concerns in the aftermath of the Persian
Gulf War of 1991 highlighted the need for compatible health information systems. Some veterans
of that period were afflicted by an array of undiagnosed symptoms that collectively came to be
known as the Gulf War Syndrome. The effort to track and treat these conditions was complicated
by incompatible medical records of the DOD and the VA. In 1996, the President’s Advisory
Committee on Gulf War Veterans Illnesses recommended that:
DOD ... should assign a high priority to dealing with the problem of lost or missing medical
records. A computerized central database is important. Specialized databases must be
compatible with the central database. Attention should be directed toward developing a
mechanism for computerizing medical data (including classified information, if and when it
is needed) in the field. DOD and VA should adopt standardized record keeping to ensure
continuity.24
President Clinton subsequently stated that “every soldier, sailor, airman, and marine will have a
comprehensive, life-long medical record of all illnesses and injuries they suffer, the care and
inoculations they receive, and their exposure to different hazards.”25 In addition, in 1998, the
18 Ibid.
19 The National Defense Authorization Act of 2008 (P.L. 110-181) required that the Secretary of Defense, in
consultation with the Secretary of Veterans Affairs, enter into an agreement with the Institute of Medicine for a study
of the physical and mental health and other readjustment needs of members and former members of the armed forces
who were deployed to Iraq and Afghanistan and their families as a result of such deployment.
20 Institute of Medicine (IOM), Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment
Needs of Veterans, Service Members, and Their Families, Washington, DC, 2010, p. 122.
21 The veteran files a claim for disability compensation by submitting VA Form 21-526 to a VA’s local Regional
Office. For more information regarding the process for filing for benefits, see CRS Report RL34626, Veterans’
Benefits: Benefits Available for Disabled Veterans, by Christine Scott et al.
22 38 U.S.C. § 5103A(b)-(c).
23 Ibid.
24 The Presidential Advisory Committee on Gulf War Veterans’ Illnesses, The Presidential Advisory Committee on
Gulf War Veterans’ Illnesses Final Report, December 1996, http://www.gulflink.osd.mil/gwvi/ch2.html#2g (accessed
February 19, 2013).
25 National Science and Technology Council, A National Obligation: Planning for Health Preparedness for and
Readjustment of the Military, Veterans, and Their Families After Future Deployments, Presidential Review Directive 5,
Executive Office of the President, Office of Science and Technology Policy, Washington, D.C., August 1998.
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Administration issued a directive that required the VA and DOD to prepare a “computer-based
patient record system that will accurately and efficiently exchange information.”26
In 1999, the Congressional Commission on Service Members and Veterans Transition Assistance
included a recommendation for the coordination of VA and DOD information management to
improve service for veterans. It recommended the establishment of a formal information business
relationship between VA and DOD. According to the Commission, the relationship should
broadly encompass all aspects of information exchange and result in an agreement addressing
issues such as compliance with the requirements of privacy and freedom of information statutes,
information security, service and development costs, data validation mechanisms, data
standardization, and technology sharing. Furthermore, it stated that a VA organizational element
should be created within the Defense Medical Data Center (DMDC), specifically responsible for
coordinating VA and DMDC business processes.27
In 2003, the President’s Task Force to Improve Health Care Delivery for Our Nation’s Veterans
made several recommendations to improve health data sharing between VA and DOD. The Task
Force recommended, among other things, that VA and DOD develop and deploy by FY2005
electronic health records that are interoperable (see text box), bi-directional, and standards-based.
It further went on to state:
During military service, information relevant to a service member’s deployment,
occupational exposures, and health conditions should follow the service member through his
or her military career. Once an individual separates from military service, the process for
determining benefits, assessing health status, and receiving care through the VA health care
system should be seamless, timely, and accurate. Better recording, tracking, and reporting of
occupational health data will improve the research base for understanding the etiology of
service-related disorders, assist in benefits determination, and improve the overall health of
today’s veterans as well as those who will follow them in the future. These goals can only be
accomplished through systems that are standards-based and coordinated between VA and
DOD.28
What Is Interoperability?
“Interoperability is the ability of an information technology (IT) system component to work with other IT system
components without special effort on the part of the user. In the government, interoperability has traditional y been
viewed as the Department of Defense (DOD) and Department of Veterans Affairs (VA) capability to share electronic
health information of [servicemembers], veterans, and shared beneficiaries. Many [servicemembers] and other
beneficiaries are also recipients of private sector health care so there is additional need to capture and share this data
as well to optimize continuity of care.”
“Interoperability can be achieved at different levels. 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). At a
lower level, electronic data are structured and viewable, but not computable. The value of data at this level is that
26 U.S. General Accounting Office, Short-Term Progress Made, but Much Work Remains to Achieve a Two-Way Data
Exchange Between VA and DOD Health Systems, GAO-04-271T, November 19, 2003, p. 1.
27 Congress established the Commission on Service Members and Veterans Transition Assistance in Title VII of the
Veterans’ Benefits Improvement Act of 1996 (P.L. 104-275). Congressional Commission on Servicemembers and
Veterans Transition Assistance, Final Report of the Congressional Commission on Servicemembers and Veterans
Transition Assistance, January 14, 1999, p. 172.
28 President’s Task Force To Improve Health Care Delivery For Our Nation’s Veterans, Final Report of the
President’s Task Force To Improve Health Care Delivery For Our Nation’s Veterans, May 2003, p. 38.
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they are structured so that data of interest to users are easier to find. At still a lower level, electronic data are
unstructured and viewable, but not computable. With unstructured electronic data, a user would have to search
through uncategorized data to find needed or relevant information. Beyond these, paper records also can be
considered interoperable (at the lowest level) because they allow data to be shared, read, and interpreted by human
beings.”
Sources: Stephen P. Hufnagel, "Interoperability," Military Medicine, vol. 174, no. 5 (May 2009), p. 43; and U.S.
Government Accountability Office, Electronic Health Records: DOD and VA Interoperability Efforts Are Ongoing; Program
Office Needs to Implement Recommended Improvements, GAO-10-332, January 2010, p. 4.
DOD-VA Electronic Health Records Sharing Efforts: 1998-2008
Since 1998, pursuant to President Clinton’s directive, DOD and VA have been pursuing various
strategies to share patient health information for active duty military personnel and veterans (see
Table 1 and Figure D-1). However, both DOD and VA efforts to meet this goal have faced
repeated changes in goals, initiatives, and deadlines.
As discussed above, in 1998 the Clinton Administration issued a directive that required the VA
and DOD to prepare “a computer-based patient record system that will accurately and efficiently
exchange information” between the two Departments.29 Following this directive, VA and DOD
began a joint program toward achieving the capability to share patient health information for
active duty military personnel and veterans. The first initiative, the Government Computer-Based
Patient Record (GCPR) project, was envisioned as an electronic interface that would allow
physicians and other authorized users at VA and DOD health facilities to access data from any of
the other agencies’ health information systems. The interface was expected to compile requested
patient information in a virtual record that could be displayed on a user’s computer screen. 30
By July 2002, VA and DOD had revised their plans towards electronically sharing patient health
data focusing on one-way transfer of patient health data from DOD to VA. The two departments
renamed the GCPR project the Federal Health Information Exchange (FHIE) program. The FHIE
initiative was completed in 2004, and enables DOD to electronically transfer servicemembers’
health information to VA when the servicemember leaves active duty (see Table 1).31
For patients being treated by both DOD and VA, the Departments continue to maintain the jointly
developed Bidirectional Health Information Exchange (BHIE) system which was implemented in
2004. Using BHIE, DOD and VA clinicians are able to access each other’s health data in real-time
(see Table 1 ). In FY2011, VA upgraded BHIE to enable providers to view inpatient notes, and
DOD neuropsychological assessments and imagery from the DOD of seriously ill and wounded
servicemembers.
29 National Science and Technology Council, A National Obligation: Planning for Health Preparedness for and
Readjustment of the Military, Veterans, and Their Families After Future Deployments, Presidential Review Directive 5,
Executive Office of the President, Office of Science and Technology Policy, Washington, D.C., August 1998,
http://www.research.va.gov/resources/pubs/pgulf98/appendixb.pdf (accessed February 20, 2013).
30 U.S. General Accounting Office, Government Computer-Based Patient Records: Better Planning and Oversight by
VA, DOD, and IHS Would Enhance Health Data Sharing, GAO-01-459, April 2001.
31 Stephen P. Hufnagel, “National Electronic Health Record Interoperability Chronology,” Military Medicine, vol. 174,
no. 5 (May 2009), p. 39.
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Additionally, in March 2004, both DOD and VA began developing the Clinical Data
Repository/Health Data Repository (CHDR). This enabled the exchange of computable,
standardized data between DOD and VA. This interoperability provides clinical users at DOD and
VA medical facilities with bi-directional, real-time exchange of data that includes at a minimum,
the exchange of outpatient pharmacy and drug allergies (see Table 1).32
The two Departments, beginning in 2004, also established the Laboratory Data Sharing
Interoperability (LDSI) initiative. LDSI allows DOD and VA to electronically communicate
orders for lab tests and their results at select locations. It should be noted that LDSI is not a
typical data sharing technology; rather it is a tool supporting lab orders.
Table 1. DOD-VA Clinical Data Sharing Initiatives
Data Sharing
Name of Program
Direction
Population Served
Viewable Data
Federal Health
One-way
Data of
•
Data includes: patient
Information Exchange
(DOD to VA)
servicemembers
demographics; laboratory
(FHIE)
separated from active
results; radiology results;
duty
outpatient pharmacy; allergies;
and hospital admission.
•
Data is not real-time; monthly
transfer of health data
Bidirectional Health
Two-way
Patients who receive
•
Data includes: allergies,
Information Exchange
(DOD to VA and VA
care in both DOD and
outpatient pharmacy, inpatient
(BHIE)
to DOD)
VA facilities (shared
and outpatient laboratory and
patients)
radiology reports, demographic
data, diagnoses, vital signs,
problem lists, family history,
social history, other history,
questionnaires, and theater
clinical data
•
Data is real-time
Clinical Data
Two-way
Patients who receive
•
Data includes: pharmacy and
Repository/Health
(DOD to VA and VA
care in both DOD and
drug allergy
Data Repository
to DOD)
VA facilities (shared
(CHDR)
patients)
•
Data sent from one
Department’s repository
becomes part of the patient’s
permanent medical record in
the other Department’s
repository
•
Data is real-time
Source: Table prepared by CRS based on information from the Defense Health Information Management
System, http://dhims.health.mil/products/data-sharing/index.aspx (accessed Friday, February 22, 2013).
As discussed above, DOD and VA have established and implemented various mechanisms for the
electronic sharing of health information at various levels. However, both Departments have
numerous and disparate data systems, as well as numerous data storage systems. While health
data is shared at various levels, DOD and VA health data is not aggregated (see Figure 1). The
32 Ibid, p.40.
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DOD and VA systems are best described as two disparate health record systems that do exchange
data.
Figure 1. Current State of DOD-VA EHR Systems
VA
DOD
CPOE
CPOE
Lab
Lab
Immunization
Immunization
Pharmacy
Pharmacy
Clinical Decision
Clinical Decision
Support
Support
Single Sign-on/
Single Sign-on/
Context Management
Context Management
Separate Patient Views
• DOD and VA health data is not
aggregated
• Disparate health record systems
Source: Interagency Program Office (IPO)
Notes: COPE= Computerized physician/provider order entry
The implications of having two separate EHR systems are illustrated in the experience of the
Lovell Federal Health Care Center (FHCC) at which DOD and VA are attempting to jointly
operate a hospital for both active duty servicemembers and veterans. A recent report by IOM
describes the limitations imposed by the existence of separate EHRs:
Using two EHR systems for the same patient population raised the specter of patient injury
because of negative drug interactions or allergic reactions occurring when the provider and
pharmacist using one EHR system is unaware of prescriptions or allergies entered into the
other EHR system. For this reason the CTG [clinical task group] had prefaced its pharmacy
options with a caveat that everything depended on orders portability for pharmacy because of
its critical role in ensuring patient safety. Orders portability for pharmacy—the ability to
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enter a prescription into either the DOD EHR system or the VA EHR system and have it
appear in the other system simultaneously so that potential drug interactions and allergies
could be recognized was one of the basic IM/IT [information management/information
technology] requirements that was supposed to be operational by October 1, 2010. As it
became clear this would not be achieved and would pose an unacceptable threat to patient
safety, an interim workaround solution had to be developed.33
Congressional Mandates
Congressional committees with oversight over veterans matters have devoted attention to health
information sharing between the DOD and VA, particularly the need to share health information
to support the transition from active duty to veterans status. Over the past several years the
committees have held numerous oversight hearings to identify the challenges facing both
Departments in achieving greater health information sharing (see Appendix B).34
In 2008, DOD and VA were charged by law to jointly develop and implement electronic health
record systems or capabilities to allow for full interoperability of personal health care information
and to accelerate the exchange of health care information in order to support the delivery of
health care by both Departments. 35 To this end, the law also established an interagency program
office (IPO) to act as a single point of accountability in the rapid development and
implementation of the electronic health record systems or capabilities, mandating full
interoperability of personal health care information and accelerating the exchange of health care
information between the Departments.36 The law specified that the IPO would be led by a
Director appointed by the Secretary of Defense with the concurrence of the Secretary of Veterans
Affairs. The IPO’s Deputy Director would be appointed by the Secretary of Veterans Affairs with
the concurrence of the Secretary of Defense. In addition to the direction, supervision, and control
of the IPO provided by the Secretary of Defense and the Secretary of Veterans Affairs, the law
specified that the IPO would receive guidance from the Department of Veterans Affairs-
Department of Defense Joint Executive.37
The law further specified that the function of the Office would be to implement, by not later than
September 30, 2009, electronic health record systems or capabilities that allow for full
interoperability of personal health care information between DOD and VA. These health records
would also comply with applicable interoperability standards, implementation specifications, and
certification criteria (including for the reporting of quality measures) of the federal government.38
A later law specified that the Director of the IPO is required, in consultation with industry and
appropriate federal agencies, to develop, or adopt from industry, information technology
33 Institute of Medicine (IOM), Evaluation of the Lovell Federal Health Care Center Merger: Findings, Conclusions,
and Recommendations, Washington, DC, 2012, p.76-77.
34 Ronald W. Gimbel and Conrad A. Clyburn, “Toward a DOD/VA Longitudinal Health Record: Politics and the
Policy Landscape,” Military Medicine, vol. 174, no. 5 (May 2009), pp. 4-5.
35 Subsection 1635(a) of the National Defense Authorization Act for Fiscal Year 2008 (P.L. 110-181) enacted January
28, 2008.
36 Subsection 1635(b) of P.L. 110-181.
37 Subsection 1635(c) of P.L. 110-181.
38 Subsection 1635(d) of P.L. 110-181.
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infrastructure guidelines and standards to enable the Departments to effectively select and utilize
information technologies to meet the interoperability requirements.39
GAO Reports
GAO has issued a series of reports on the Departments’ efforts to develop fully interoperable
electronic health record systems or capabilities as required by the FY2008 National Defense
Authorization Act (P.L. 110-181). Findings from GAO studies of this issue may be broadly
summarized as follows: 1) VA and DOD face significant challenges in achieving long-term data
sharing capability; 2) while the two Departments have developed a strategy at the higher levels,
both Departments lack objective, quantifiable, and measurable goals to assess their success in
achieving full electronic health record interoperability;40 and 3) VA and DOD lack mechanisms
for identifying and implementing efficient and effective information technology solutions to
jointly address both Departments’ common health care system needs as a result of barriers in
three key IT management areas—strategic planning, enterprise architecture, and investment
management. With respect to these three areas, GAO has drawn the following conclusions:41
• Strategic planning: The two Departments have been unable to articulate explicit
plans, goals, and time frames for jointly addressing the health IT requirements
common to both Departments’ electronic health record systems.
• Enterprise architecture: Although VA and DOD have taken steps toward
developing and maintaining artifacts related to a joint health architecture (i.e., a
description of business processes and supporting technologies), the architecture is
not sufficiently mature to guide the Departments’ joint health IT modernization
efforts. For example, the Departments have not defined how they intended to
transition from their current architecture to a planned future state.
• Investment management: VA and DOD have not established a joint process for
selecting IT investments based on criteria that consider cost, benefit, schedule,
and risk elements, which would help to ensure that a chosen solution both meets
the Departments’ common health IT needs and provides better value and benefits
to the government as a whole.
Appendix C provides summaries of GAO studies and testimony on DOD and VA electronic
health information sharing, from 2001 to its most recent report in November 2012.
39 Subsection 252 of P.L. 110-417.
40 U.S. Government Accountability Office, Electronic Health Records: DOD’s and VA’s Sharing of Information Could
Benefit from Improved Management, GAO-09-268, February 2009.
41 U.S. Government Accountability Office, Electronic Health Records: DOD and VA Should Remove Barriers and
Improve Efforts to Meet Their Common System Needs, GAO-11-265, February 2011.
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Current Status
Interagency Program Office (IPO)
The IPO was officially formed by the DOD and the VA on April 17, 2008, and staffed by
temporary personnel provided by both Departments. On December 30, 2008, a Delegation of
Authority Memorandum was signed by the Deputy Secretary of Defense, assigning the IPO to the
Under Secretary of Defense for Personnel and Readiness [USD(P&R)]. The memorandum
directed USD(P&R) to appoint a permanent IPO Director with concurrence of the VA Secretary.
This memorandum allowed the DOD to begin the process of recruiting and hiring IPO leadership
and staff.
In January 2009, the IPO completed its charter articulating, among other things, its mission and
functions with respect to attaining interoperable electronic health data. The charter was signed by
the Deputy Secretaries on September 24, 2009.42 The charter further identified the office’s
responsibilities in carrying out its mission, in areas such as oversight and management,
stakeholder communication, and decision-making. On October 27, 2011, the two Departments
signed a revised IPO Charter that stated that the IPO serves as the single point of accountability
for the Departments in the development and implementation of the integrated Electronic Health
Record (iEHR).43,44
Initial Interoperability Goals
The Interagency Clinical Informatics Board (ICIB), made up of senior clinical leaders from both
DOD and VA, issued an Information Interoperability Plan (IIP) in September 2008.45 This
document defined “interoperability” as “the ability of users to equally interpret (understand)
unstructured or structured information which is shared (exchanged) between them in electronic
form.” Based on this definition, DOD and VA adopted six interoperability initiatives to be
completed by September 2009 in order to satisfy the interoperability requirements:
1. Expand Essentris46 implementation in DOD.
2. Demonstrate the operation of the Partnership Gateways47 in support of joint
DOD/VA health information sharing.
3. Enhance sharing of the social history data captured by DOD with VA.
42 Joint Executive Council, Annual Report 2009, page 3 available at http://prhome.defense.gov/docs/
2009%20VA%20DoD%20Joint%20Executive%20Council%20Annual%20Report%20and%20Joint%20Strategic%20P
lan.pdf ((accessed February 20, 2013).
43 U.S. Government Accountability Office, VA and DOD Health Care: Department-Level Actions Needed to Assess
Collaboration Performance, Address Barriers, and Identify Opportunities, GAO-12-992, September 2012, p. 16.
44 The current charter is available at http://www.tricare.mil/tma/ipo/documents/IPO.pdf (accessed February 20, 2013).
45 DOD/VA Information Interoperability Plan, September 2008, page 71. http://tricare.mil/tma/
congressionalinformation/downloads/IIPSept15.pdf
46 Essentris® is a commercial off-the-shelf inpatient records system from CliniComp, Intl. and procured by DOD in
2009.
47 Based on the results of a network capability analysis measuring inbound and outbound bandwidth, DOD/VA secure
Internet gateways to support expanded bandwidth requirements.
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4. Demonstrate an initial capability for DOD to scan medical documents into the
DOD EHR and forward those documents electronically to VA.
5. Provide all servicemembers’ health assessment data stored in the DOD EHR to
the VA in such a fashion that questions are associated with the responses.
6. Provide initial capability to share electronic access to separation physical exam
information captured in the DOD EHR with the VA.
As a result of meeting these six objectives, DOD and VA reported to Congress that they had
satisfied the September 30, 2009 requirement for “full” interoperability.48
DOD-VA iEHR
Although the two Departments reported to Congress that the statutory interoperability goal was
met, they nevertheless continued to work on integrating the DOD and VA EHR systems on their
own initiative. The Secretaries of VA and Defense committed their respective Departments to
jointly develop and implement the next generation of EHR capabilities with integrated objectives
towards implementing a common integrated EHR (iEHR). On March 17, 2011, the Secretary of
Veterans Affairs and the Secretary of Defense reached an agreement to work cooperatively on the
development of a common electronic health record and to sunset corresponding legacy systems
and transition to a new iEHR by 2017. An agreement was signed in July 2011 to move forward on
this initiative.49 The Secretaries of DOD and VA validated the goals and objectives of the iEHR,
and established that the iEHR would:
• Promote transparency;
• Enable the commitments for common business processes (such as billing);
• Capitalize on opportunities for influencing a mutual course for both Departments’
EHR modernization;
• Maximize interoperability;
• Manage efficiency of cost and scale;
• Accelerate the delivery of health services;
• Improve the quality of delivered services through reliability, maintainability,
completeness, and accuracy of data captured;
• Improve interoperability and data sharing of medical history between
Departments;
• Support electronic medical data capture and exchange between the private U.S.
health care system and the federal, state, and local government;
48 DOD/VA Interagency Program Office Report to Congress 2009, page 29, http://www.tricare.mil/tma/
congressionalinformation/downloads/2010310/Annual%20RTC%20-
%20Fully%20Interoperable%20Electronic%20Personal%20Health%20Information%20for%20DoD%20and%20VA.p
df (accessed February 20, 2013).
49 Department of Defense , Background on DOD and VA Chicago Announcement on Virtual Lifetime Electronic
Record (VLER) and Integrated Electronic Health Record (iEHR), Fact Sheet, 2012, http://www.defense.gov/news/
EHRDoDVAFactSheet.pdf (accessed February 20, 2013).
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• Provide a quality, satisfactory patient experience; and
• Reduce overall cost of health IT investments.50
Under this iEHR initiative, the IPO would have developed EHR capabilities in six increments
over a period of five years beginning in 2012.51
February 2013 Announcement
On February 5, 2013, Secretaries Shinseki and Panetta announced that the two Departments plan
to improve data interoperability before the end of 2013, by standardizing health care data,
accelerating the exchange of real-time data between VA and DOD, allowing VA and DOD
patients to download their medical records, and a single EHR display system for DOD and VA
providers. Secretary Panetta stated that “Rather than building a single integrated system from
scratch, we will focus our immediate efforts on integrating VA and DOD health data as quickly as
possible, by focusing on interoperability and using existing solutions.” 52 On February 8, 2013,
DOD issued a request for information to replace its existing EHR systems53 with a single EHR
system for all DOD beneficiaries.54
Concluding Observations
Both the DOD and the VA have undertaken a number of initiatives designed to encourage the two
Departments to share their health care information electronically in order to serve the medical
needs of servicemembers and veterans. On the other hand, moderate progress has been made to
design and plan EHR systems around a need to insure compatibility with each other’s systems.
Nevertheless, it is unclear at this time what the long-term implications of the most recent change
in the program strategy will be for creating an EHR that would share medical information not
only between DOD and VA, but also with entities outside the two Departments such as private
medical providers.
50 Department of Defense TRICARE Management Activity, DOD/VA Interagency Program Office Technical
Specifications Request for Information (RFI) Questions to Industry, Solicitation Number: TMA-iEHR-IPO-RFI-07-
2012, July 18, 2012, p. 2.
51 In very technical terms, the iEHR program would have used a service oriented architecture (SOA) construct to
acquire the services and infrastructure necessary to provide defined capabilities and ensure successful management,
oversight, operations and maintenance of services, applications, infrastructure and their associated technologies. The
infrastructure would have included an Enterprise Service Bus (ESB) with an integrated federated data repository that
could have performed reach back to legacy repositories. SOA services to be developed would have included common
services and adapters that access open or proprietary Application Program Interfaces (APIs) for clinical ancillary
automated information system (AISs), allowing for a true plug and play infrastructure.
52 U.S. Department of Defense Office of the Assistant Secretary of Defense (Public Affairs) News Transcript, Remarks
by Secretary Panetta and Secretary Shinseki from the Department of Veterans Affairs February 5, 2013
http://www.defense.gov/transcripts/transcript.aspx?transcriptid=5187(accessed February 20, 2013).
53 DOD’s current EHR systems include the Armed Forces Health Longitudinal Technology Application (AHLTA),
Composite Health Care System (CHCS), and Inpatient System Essentris®.
54 Department of Defense TRICARE Management Activity, Medical Electronic DOD Integrated Core System
(MEDICS), Request for Information (RFI), Solicitation Number: HT0012-RFI-0008, February 8, 2013.
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Appendix A. Acronyms
Table A-1. List of Acronyms
BHIE
Bidirectional Health Information Exchange
CHDR
Clinical Data Repository/Health Data Repository
CPOE
Computerized Physician/Provider Order Entry
DMDC
Defense Medical Data Center
DOD
Department of Defense
EHR
Electronic Health Record
FHCC
Federal Health Care Center
FHIE
Federal Health Information Exchange
GAO Government
Accountability Office
GCPR
Government Computer-Based Patient Record
HIT
Health Information Technology
ICIB
Interagency Clinical Informatics Board
iEHR
Integrated Electronic Health Record
IIP
Information Interoperability Plan
IOM
Institute of Medicine
IPO Interagency
Program
Office
IT Information
Technology
LDSI
Laboratory Data Sharing Interoperability (LDSI) initiative
VA
Department of Veterans Affairs
Source: Table prepared by CRS.
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Appendix B. Selected Congressional Hearings,
2000-2011
• U.S. Congress, House Committee on Veterans’ Affairs, Subcommittee on Health,
VA/DOD Health Care Sharing, 106th Cong., 2nd sess., May 17, 2000
(Washington: GPO, 2000).
• U.S. Congress, House Committee on Veterans’ Affairs, Handoff or Fumble? Are
DOD and VA Providing Seamless Health Care Coverage To Transitioning
Veterans?, 108th Cong., 1st sess., October 16, 2003 (Washington: GPO, 2004).
• U.S. Congress, House Committee on Veterans’ Affairs, Subcommittee on
Oversight and Investigations, VA-DOD Shared Medical Records—20 Years and
Waiting, 108th Cong., 1st sess., November 19, 2003 (Washington: GPO, 2005).
• U.S. Congress, House Committee on Veterans’ Affairs, Subcommittee on
Oversight and Investigations, Department Of Veterans Affairs Role In The Future
of Electronic Health Records, 108th Cong., 2nd sess., May 19, 2004 (Washington:
GPO, 2005).
• U.S. Congress, Senate Committee on Veterans’ Affairs, DOD/VA Collaboration
And Cooperation to Meet the Needs of Returning Servicemembers, 110th Cong.,
1st sess., January 23, 2007 (Washington: GPO, 2007).
• U.S. Congress, Senate Committee on Veterans’ Affairs, DOD/VA Collaboration
And Cooperation To Meet The Health Care Needs Of Returning Servicemembers,
110th Cong., 1st sess., March 27, 2007 (Washington: GPO, 2007).
• U.S. Congress, House Committee on Veterans’ Affairs, Subcommittee on
Oversight and Investigations, Sharing of Electronic Medical Records Between the
U.S. Department of Defense and the U.S. Department of Veterans Affairs, 110th
Cong., 1st sess., May 8, 2007 (Washington: GPO, 2008).
• U.S. Congress, Senate Committee on Veterans’ Affairs, Oversight Hearing:
Update on VA and DOD Cooperation and Collaboration, 110th Cong., 2nd sess.,
April 23, 2008 (Washington: GPO, 2009).
• U.S. Congress, Senate Committee on Veterans’ Affairs, Hearing on Sharing of
VA/DOD Electronic Health Information, 110th Cong., 2nd sess., September 24,
2008 (Washington: GPO, 2009).
• U.S. Congress, House Committee on Veterans’ Affairs, Subcommittee on
Oversight and Investigations, Examining the Progress of Electronic Health
Record Interoperability Between the U.S. Department Of Veterans Affairs and
U.S. Department Of Defense, 111th Cong., 1st sess., July 14, 2009 (Washington:
GPO, 2010).
• U.S. Congress, Senate Committee on Veterans’ Affairs, Review of the VA and
DOD Integrated Disability Evaluation System, 111th Cong., 2nd sess., November
18, 2010 (Washington: GPO, 2011).
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• U.S. Congress, Senate Committee on Veterans’ Affairs, Seamless Transition:
Improving VA/DOD Collaboration, 112th Cong., 1st sess., May 18, 2011
(Washington: GPO, 2011).
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Appendix C. GAO Reports/Testimony on VA and
DOD Sharing of Patient Health Information
Table C-1. GAO Reports/Testimony on VA and DOD Sharing of Patient
Health Information
Date/Report or Testimony
Summary of Findingsa
September 2012, GAO-12-992
Among other things, VA and DOD face a number of significant barriers that
hinder their col aboration efforts. At col aboration sites, the departments’ IT
barriers hinder ongoing efforts in many ways. For example, the North Chicago
Federal Health Care Center joint venture hired five full-time pharmacists
specifically to conduct manual checks of patient records to reconcile allergy
information and identify possible interactions between drugs prescribed by
providers in both VA and DOD systems. Similarly, Biloxi joint venture officials
reported having to rely on inefficient and time-consuming approaches to share
information, including manually copying or transferring medical information
such as diagnostic images between VA’s and DOD’s IT systems, or faxing
information to their col aboration partner, where it must be entered into the
partner’s IT system.
February 2, 2011, GAO-11-265
DOD and VA have not articulated explicit plans, goals, and time frames for
jointly addressing the health IT requirements common to both Departments’
electronic health record systems, and the Departments’ joint strategic plan
does not discuss how or when DOD and VA propose to identify and develop
joint solutions to address their common health IT needs. In addition, although
DOD and VA have taken steps toward developing and maintaining artifacts
related to a joint health architecture (i.e., a description of business processes
and supporting technologies), the architecture is not sufficiently mature to
guide the Departments’ joint health IT modernization efforts. For example,
the Departments have not defined how they intend to transition from their
current architecture to a planned future state. Furthermore, DOD and VA
have not established a joint process for selecting IT investments based on
criteria that consider cost, benefit, schedule, and risk elements, which limits
their ability to pursue joint health IT solutions that both meet their needs and
provide better value and benefits to the government as a whole.
January 28, 2010, GAO-10-332
DOD and VA previously established six objectives that they identified as
necessary for achieving full interoperability; they have now met the remaining
three interoperability objectives that GAO previously reported as being
partial y achieved—expand questionnaires and self-assessment tools, expand
DOD’s inpatient medical records system, and demonstrate initial document
scanning. As a result of meeting the six objectives, the Departments’ officials,
including the co-chairs of the group responsible for representing the clinician
user community, believe they have satisfied the September 30, 2009,
requirement for full interoperability. Nevertheless, DOD and VA are planning
additional actions to further increase their interoperable capabilities and
address clinicians’ evolving needs for interoperable electronic health records.
The interagency program office is not yet positioned to function as a single
point of accountability for the implementation of interoperable electronic
health record systems or capabilities. The Departments have made progress in
setting up their interagency program office by hiring additional staff, including a
permanent director.
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Date/Report or Testimony
Summary of Findingsa
July 28, 2009, GAO-09-775
DOD and VA have continued to increase electronic health information
interoperability. In particular, the Departments have taken steps to meet their
six interoperability objectives by September 30, 2009. However, for two of
the six interoperability objectives, the Departments subsequently plan to
perform significant additional activities that are necessary to meet clinicians’
needs. Further, the Departments’ lack of progress in establishing fundamental
IT management capabilities that are specific responsibilities of the interagency
program office contributes to uncertainty about the extent to which the
Departments will progress toward achievement of full interoperability by the
deadline. While the Departments have general y made progress toward
making the program office operational, the office has not yet completed a
project plan or a detailed integrated master schedule. Without these
important tools, the office is limited in its ability to effectively manage and
provide meaningful progress reporting on the delivery of interoperable
capabilities that are intended to improve the quality of health care provided to
our nation’s veterans.
July 14, 2009, GAO-09-895T
VA and DOD have continued to increase electronic health information
interoperability, and have taken steps to meet the six objectives that they
identified as necessary to achieve full interoperability by September 30, 2009.
However, for two of the six interoperability objectives, the Departments
subsequently plan to perform significant additional activities that are necessary
to meet clinicians’ needs. Further, the Departments’ lack of progress in
establishing fundamental IT management capabilities that are the specific
responsibilities of the interagency program office contributes to uncertainty
about the extent to which they will achieve full interoperability by the
deadline.
March 12, 2009, GAO-09-427T
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. Final y, 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.
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Date/Report or Testimony
Summary of Findingsa
January 28, 2009, GAO-09-268
In the more than 10 years since DOD and VA began col aborating to
electronically share health information, the two Departments have increased
interoperability. Nevertheless, while the Departments continue to make
progress, the manner in which they report progress—by reporting increases
in interoperability over time—has limitations. These limitations are rooted in
the Departments’ plans, which identify interoperable capabilities to be
implemented, but lack the results-oriented (i.e., objective, quantifiable, and
measurable) goals and associated performance measures that are a necessary
basis for effective management. Without establishing results-oriented goals,
then reporting progress using measures relative to the established goals, the
Departments and their stakeholders do not have the comprehensive picture
that they need to effectively manage their progress toward achieving increased
interoperability. Further constraining the Departments’ management
effectiveness is their slow pace in addressing GAO’s July 2008
recommendation related to setting up the interagency program office that
Congress called for to function as a single point of accountability in the
development and implementation of electronic health record capabilities.
September 24, 2008, GAO-08-
DOD and VA are sharing some, but not all, electronic health information. This
1158T
includes exchanging some information in computable form, which is the
highest level of interoperability. In other cases, data can be viewed only—a
lower level of interoperability that still provides clinicians with important
information. The Departments have undertaken a number of initiatives,
resulting in varied sharing capabilities. However, information is still being
captured in paper records at many DOD medical facilities, and not all
electronic health information is being shared.
July 28, 2008, GAO-08-954
DOD and VA are currently sharing more health information than ever before,
including exchanging some at the highest level of interoperability, that is, in
computable form. The Departments also have efforts under way to share
additional information. Additional issues remaining to be addressed include
electronic sharing of the information in paper-based health records and the
completion of their long-range plans to develop fully interoperable health
information systems. According to the Departments, the DOD/VA
Information Interoperability Plan is to address these and other issues. Once
the plan is finalized and approved by DOD and VA officials, GAO intends to
perform an assessment of the plan. However, if the plan includes the essential
elements needed to guide the Departments in achieving their long-term goal
of seamless sharing of health information, it could improve the prospects for
the successful achievement of this goal.
Further enhancing interoperability depends on adherence to common
standards. The two Departments have agreed on standards and are working
with each other and federal groups to help ensure that their systems are both
interoperable and compliant with current and emerging federal standards.
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Date/Report or Testimony
Summary of Findingsa
October 24, 2007, GAO–08–207T
Under their long-term initiative, the modern health information systems being
developed by each department are to share standardized computable data
through an interface between data repositories associated with each system.
The repositories have now been developed, and the Departments have begun
to populate them with limited types of health information. In addition, the
interface between the repositories has been implemented at seven VA and
DOD sites, allowing computable outpatient pharmacy and drug allergy data to
be exchanged. Nevertheless, the Departments must still agree to standards
for the remaining categories of medical information, populate the data
repositories with this information, complete the development of the two
modernized health information systems, and transition from their existing
systems. Further, the Departments have established ad hoc processes to meet
the immediate need to provide data on severely wounded servicemembers to
VA’s polytrauma centers, which specialize in treating such patients. While
these multiple initiatives and ad hoc processes have facilitated degrees of data
sharing, they nonetheless highlight the need for continued efforts to integrate
information systems and automate information exchange. At present, it is not
clear how all the initiatives are to be incorporated into an overall strategy
focused on achieving the Departments’ goal of comprehensive, seamless
exchange of health information.
September 19, 2007,
VA achieved a milestone in the long-term effort to share electronic health
GAO–07–1246T
information with DOD, having begun to exchange limited medical data with
DOD (at selected sites) through an interface between the data repositories
for the modern health information systems that each department is
developing. Nevertheless, to achieve their long-term vision, VA and DOD
have much work still to do (such as extending the current capability
throughout both Departments), and the two Departments have not yet
projected a final completion date for the whole initiative.
July 18, 2007, GAO–07–1108T
VA and DOD have made progress in both their long-term and short term
initiatives to share health information, but much work remains to achieve the
goal of a shared electronic medical record and seamless transition between
the two Departments. In the long-term project to develop modernized health
information systems, the Departments have begun to implement the first
release of the interface between their modernized data repositories, and
computable outpatient pharmacy and drug allergy data are being exchanged at
seven VA and DOD sites. However, significant work remains including
agreeing to standards for the remaining categories of medical information and
populating the data repositories with all this information. The two
Departments have also made progress in their short-term projects to share
information in existing systems. Through all these efforts, VA and DOD are
achieving exchanges of health information. However, these exchanges are as
yet limited, and it is not clear how they are to be integrated into an overall
strategy toward achieving the Departments’ long-term goal of comprehensive,
seamless exchange of health information. Consequently, it remains essential
for the Departments to develop a comprehensive project plan to guide their
efforts to completion, in line with GAO’s earlier recommendations.
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Date/Report or Testimony
Summary of Findingsa
May 8, 2007, GAO–07–852T
In the long-term project to develop modernized health information systems,
the Departments have begun to implement the first release of the interface
between their modernized data repositories, and computable outpatient
pharmacy and drug allergy data are being exchanged at seven VA and DOD
sites. Although the data being exchanged are limited, implementing this
interface is a milestone toward the long-term goal of modernized systems
with interoperable electronic medical records. Besides completing the Federal
Health Information Exchange (FHIE), the Departments have made progress on
two demonstration projects. In addition to their technology efforts, the two
Departments have undertaken ad hoc activities to accelerate the transmission
of health information on severely wounded patients from DOD to VA’s four
polytrauma centers, which care for veterans and servicemembers with
disabling injuries to more than one physical region or organ system.
April 30, 2007, GAO-07-554R
In March 2004, DOD and VA began col aborating on a long-term initiative to
make their outpatient pharmacy data computable. To help ensure that all
shared patients benefit from the exchange of computable outpatient pharmacy
data, the Secretary of Defense and the Secretary of Veterans Affairs should
expedite certain ongoing efforts. Specifically, GAO recommend that: (1) the
Secretary of Defense and the Secretary of Veterans Affairs expedite efforts to
develop a solution for activating shared patients when patients’ identifying
information does not match exactly, (2) the Secretary of Defense expedite
efforts to assign a unique DOD identification number to VA patients who
were discharged from active duty before 1997, (3) the Secretary of Veterans
Affairs expedite efforts to expand to all VA sites the capability to automatically
check DOD data that are exchanged through CHDR, and (4) the Secretary of
Defense and the Secretary of Veterans Affairs expedite the development of
written guidelines for all sites to use for defining and identifying shared
patients.
June 22, 2006, GAO–06–905T
VA and DOD are implementing limited, near-term demonstration projects,
and they are making progress toward their long-term effort to share
electronic patient health data. The Bidirectional Health Information Exchange,
implemented at 16 sites, allows the two-way exchange of health information
on shared patients in text format. The Laboratory Data Sharing Interface
application, implemented at 6 sites, is used to facilitate the electronic
transfer/sharing of orders for laboratory work and the results of the work. In
their longer term efforts to achieve a virtual medical record, VA and DOD
have more to do to achieve the two-way electronic data exchange capability
originally envisioned. They have made progress in, for example, preparing data
for exchange, and they have implemented three of GAO’s four earlier
recommendations. However, they have not yet developed a clearly defined
project management plan that gives a detailed description of the technical and
managerial processes necessary to satisfy project requirements, as GAO
recommended. Moreover, the Departments have experienced delays in their
efforts to begin exchanging computable patient health data.
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Departments of Defense and Veterans Affairs: Status of the iEHR
Date/Report or Testimony
Summary of Findingsa
September 28, 2005, GAO–05–
VA and DOD had begun to implement applications that exchange limited
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electronic medical information between the Departments’ existing health
information systems. These applications were developed through two
information technology demonstration projects: (1) Bidirectional Health
Information Exchange is a project to achieve the two-way exchange of health
information on shared patients, and (2) Laboratory Data Sharing Interface is
an application used to facilitate the electronic transfer/sharing of orders for
laboratory work and the results of the work. Since GAO’s last report on the
Departments’ efforts to achieve a virtual medical record, VA and DOD have
taken several actions, but the Departments continue to be far from achieving
the two-way electronic data exchange capability originally envisioned. The
Departments have implemented three recommendations that GAO made in
June 2004, but have not yet developed a clearly defined project management
plan that gives a detailed description of the technical and managerial processes
necessary to satisfy project requirements, as GAO previously recommended.
Moreover, the Departments have experienced delays in their efforts to begin
exchanging computable patient health data; they have not yet fully populated
the data repositories that are to store the medical data for their future health
systems.
VA and DOD are proceeding with actions intended to support the sharing of
health data, but continue to be far from achieving the two way electronic data
exchange capability envisioned in the HealthePeople (Federal) strategy. The
Departments are continuing to take actions to develop their individual health
information systems that are critical to exchanging patient health information
and to define data standards that are essential to the common sharing of
health information. In addition, department officials stated that they are
proceeding with a pharmacy data prototype initiative, begun in March 2004, to
satisfy a mandate of the Bob Stump National Defense Authorization Act for
Fiscal Year 2003 (P.L. 107-314, sec. 724) as an initial step toward achieving
HealthePeople (Federal). At this stage, however, they have not developed a
strategy to explain how this project will contribute to defining the
technological solution for the data exchange capability. As such, VA and DOD
continue to lack a clearly defined architecture and technological solution for
developing the electronic interface and associated capability for exchanging
patient health information between their new systems. Moreover, the
Departments remain challenged to articulate a clear vision of how this
capability will be achieved, and in what timeframe.
Since 1998 VA and DOD have been trying to achieve the capability to share
patient health care data electronically. The original effort—the government
computer-based patient record (GCPR) project—included the Indian Health
Service (IHS) and was envisioned as an electronic interface that would allow
physicians and other authorized users at VA, DOD, and IHS health facilities to
access data from any of the other agencies’ health information systems. The
interface was expected to compile requested patient information in a virtual
record that could be displayed on a user’s computer screen.
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Departments of Defense and Veterans Affairs: Status of the iEHR
Date/Report or Testimony
Summary of Findingsa
March 17, 2004, GAO–04–402T
VA and DOD had made little progress since November 2003 toward defining
how they intended to achieve the two-way exchange of patient health
information under the HealthePeople (Federal) initiative. While VA officials
recognized the importance of an architecture to describe in detail how the
Departments would electronically interface their health systems, they
continued to rely on a less-specific, high-level strategy—in place since
September 2002—to guide the development and implementation of this
capability. The Departments intended to rely on a pharmacy prototype
project undertaken in March 2004 to better define the electronic interface
needed to exchange patient health data, but had not ful y determined the
approach or requirements for this undertaking. Thus, there was little evidence
of how this project would contribute to defining a specific architecture and
technological solution for achieving a two-way exchange of patient health
information. These uncertainties were further complicated by the absence of
sound project management to guide the Departments’ actions on the
HealthePeople (Federal) initiative. Although progress toward defining data
standards continued, delays had occurred in VA’s and DOD’s development
and deployment of their individual health information systems, critical for
achieving the electronic interface.
November 19, 2003, GAO–04–
The one-way transfer of health information resulting from VA’s and DOD’s
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near-term solution—the FHIE—represented a positive undertaking and had
enabled electronic health data from separated (retired or discharged)
servicemembers contained in DOD’s Military Health System Composite
Health Care System to be transmitted monthly to a VA FHIE repository,
giving VA clinicians more ready access to DOD health data, such as
laboratory, pharmacy, and radiology records, on almost two mil ion patients.
The Departments’ longer term strategy to enable electronic, two-way
information sharing—HealthePeople (Federal)—was farther out on the
horizon, and VA and DOD faced significant challenges in implementing a full
data exchange capability. Although a high-level strategy existed, the
Departments had not clearly articulated a common health information
infrastructure and architecture to show how they intended to achieve the
data exchange capability or what they would be able to exchange by the end
of 2005. Critical to achieving the two-way exchange was completing the
standardization of the clinical data that the Departments planned to share.
September 26, 2002,
VA and DOD reported some progress in achieving the capability to share
GAO–02–1054T
patient health care data under the Government Computer-Based Patient
Record (GCPR) initiative. The agencies had, since March 2002, formally
renamed the initiative the Federal Health Information Exchange and begun
implementing a more narrowly defined strategy involving the one-way transfer
of patient health data from DOD to VA; a two-way exchange was planned by
2005.
March 13, 2002, GAO–02–369T
VA had achieved limited progress in its joint efforts with DOD and the Indian
Health Service to create an interface for sharing data in their health
information systems, as part of Government Computer-Based Patient Record
(GCPR) strategies for implementing the project continued to be revised, its
scope had been substantially narrowed from its original objectives, and it
continued to operate without clear lines of authority or comprehensive,
coordinated plans. Consequently, the future success of this project remained
uncertain, raising questions as to whether it would ever fully achieve its
original objective of allowing health care professionals to share clinical
information via a comprehensive, lifelong medical record.
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Departments of Defense and Veterans Affairs: Status of the iEHR
Date/Report or Testimony
Summary of Findingsa
February 27, 2002 ,GAO–02–478T
DOD’s and VA’s numerous databases and electronic systems for capturing
mission-critical data, including health information, were not linked, and
information could not be readily shared. DOD had several initiatives under
way to link many of its information systems—some with VA. For example, to
create a comprehensive, lifelong medical record for servicemembers and
veterans and to allow health care professionals to share clinical information,
the Departments, along with the Indian Health Service, initiated the
Government Computer-Based Patient Record (GCPR) project in 1998.
However, several factors, including planning weaknesses, competing priorities,
and inadequate accountability, made it unlikely that they would achieve a
GCPR or realize its benefits in the near future. To strengthen management
and oversight of the project, GAO recommended designating a lead entity
with clear lines of authority for the project and the creation of comprehensive
and coordinated plans for sharing meaningful, accurate, and secure patient
health data. For the near term, DOD and VA had decided to reconsider their
approach to GCPR and focus on allowing VA to access selected
servicemembers’ health data captured by DOD, such as laboratory and
radiology results, outpatient pharmacy data, and patient demographic
information. However, GCPR would not provide VA with access to
information on the health status of personnel when they entered military
service; on medical care provided to Reservists while not on active duty; or
on the care military personnel received from providers outside DOD,
including those from TRICARE.
January 24, 2002, GAO–02–377T
DOD improved its medical surveillance system under Operation Joint
Endeavor. However, system problems included lack of a single, comprehensive
electronic system to document and access medical surveillance data. Some
DOD initiatives to improve information technology capability were several
years away from full implementation. The ability of VA to fulfill its role in
serving veterans and providing backup to DOD in times of war was to be
enhanced as DOD increased its medical surveillance capability. GCPR was a
joint DOD/VA initiative in conjunction with the Indian Health Service to link
information systems. However, because of planning weaknesses, competing
priorities, and inadequate accountability, it was unlikely that the Departments
would accomplish GCPR or realize its benefits in the near future. To
strengthen management and oversight of the initiative, GAO again
recommended designating a lead entity with clear lines of authority for the
project and the creation of comprehensive and coordinated plans for sharing
meaningful, accurate, and secure patient health data.
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Departments of Defense and Veterans Affairs: Status of the iEHR
Date/Report or Testimony
Summary of Findingsa
October 16, 2001, GAO–02–173T
DOD and VA were establishing a medical surveillance system for the health
care needs of military personnel and veterans. The system was to collect and
analyze uniform information on deployments, environmental health threats,
disease monitoring, medical assessments, and medical encounters. GAO
identified weaknesses in DOD’s medical surveillance capability and
performance in the Gulf War and Operation Joint Endeavor, and uncovered
deficiencies in its ability to col ect, maintain, and transfer accurate data. The
department had several initiatives under way to improve the reliability of
deployment information and to enhance its information technology
capabilities, although some initiatives were several years away from full
implementation. VA’s ability to serve veterans and provide backup to DOD in
times of war was to be enhanced as DOD increased its medical surveillance
capability. GCPR was one initiative to link the Departments’ information
systems. However, because of planning weaknesses, competing priorities, and
inadequate accountability, it was unlikely that they would accomplish GCPR or
realize its benefits in the near future. To strengthen management and
oversight of the initiative, GAO recommended designating a lead entity with
clear lines of authority for the project and the creation of comprehensive and
coordinated plans for sharing meaningful, accurate, and secure patient health
data.
April 2001, GAO-01-459
In 1998, the Government Computer-Based Patient Record (GCPR) project
was initiated by VA, DOD, and IHS, which was included in the effort because
of its population-based research expertise and its long-standing relationship
with VA. With accountability for GCPR blurred across several management
entities, basic principles of sound IT project planning, development, and
oversight have not been fol owed, creating barriers to progress. For example,
clear goals and objectives have not been set; detailed plans for the design,
implementation, and testing of the interface have not been developed; and
critical decisions are not binding on al partners. In addition, GCPR plans have
not resolved data incompatibilities and other differences that complicate the
electronic exchange of health information among the three agencies’ facilities.
Final y, concerns related to developing a comprehensive strategy to guarantee
the privacy and security of health information shared through GCPR have not
been addressed.
Sources: GAO Reports and Testimony and U.S. Congress, House Committee on Veterans’ Affairs,
Subcommittee on Oversight and Investigations, Sharing of Electronic Medical Information Between the U.S.
Department of Defense and the U.S. Department of Veterans Affairs, 110th Cong., 1st sess., October 24, 2007
(Washington: GPO, 2008), pp. 86-91.
Notes:
AHLTA= Armed Forces Health Longitudinal Technology Application
BHIE =Bidirectional Health Information Exchange
CHDR= Clinical Data Repository/Health Data Repository
DOD= Department of Defense
FHCC= Federal Health Care Center
FHIE= Federal Health Information Exchange
GCPR= Government Computer-Based Patient Record
IT= information technology
IHS= Indian Health Service
LDSI =Laboratory Data Sharing Interface
MHS= Military Health System
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Departments of Defense and Veterans Affairs: Status of the iEHR
VA= Department of Veterans Affairs
VistA =Veterans Health Information Systems and Technology Architecture
VHA= Veterans Health Administration
VLER =Virtual Lifetime Electronic Record
a. Summaries have been adapted verbatim from GAO reports or have been paraphrased to highlight GAO
findings pertaining to DOD-VA health information sharing.
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Appendix D. Milestones of Selected DOD and VA Health Records
Development and Sharing Efforts
Figure D-1. Selected DOD and VA Health Records Development and Sharing Efforts
2009: Planning begins
for next EHR system
2005: CHCS II renamed
AHLTA
1998: CHCS I
2010: DOD pauses EHR
deployed
Begins widespread
development given
worldwide
deployment and use
possibility of DOD/VA
collaborative system
1988: CHCS I
development
2000: CHCS II
2006: AHLTA
begins
begins initial
deployed
deployment
worldwide
Dec 2010: DOD and VA
Oct 2011: IPO
directed to begin
DEPARTMENT
Feb 2013: DOD and
established to serve as
analysis of VA/DOD
VA will concentrate
the point of
OF DEFENSE
integrated electronic
on integrating VA
accountability for the
health record (iEHR)
and DOD health
development of the
systems
data by focusing on
iEHR
interoperability and
using existing
2002: GCPR revised;
technological
reformed as FHIE
Development of DOD
solutions.
2004: FHIE
and VA Electronic
operational
2007: BHIE and LDSI
programs
Health Record Systems
1998: DOD and VA
CHDR, BHIE,
functional
begin work on GCPR
and LDSI
programs
Mar 2011: Secretary of
Feb 2012: Initial IPO
started
Defense and Secretary of
Advisory Board Meeting
the VA agree to work
toward a common EHR
Feb 2012: IPO leadership
system
chosen
DEPARTMENT OF
1982: Congress endorses
VETERANS AFFAIRS
2005: Advances to VistA
development of VA
systems to allow for
patient computer system
1996: VistA
image storage
2010: Blue Button
introduced
becomes operational,
1982: DHCP, the VHA’s
allows Veterans to
first electronic
2003: My HealtheVet
download their personal
information system, was
1994: Improvements
program is deployed
health information from
introduced
begun on DHCP
My Healthevet
(renamed VistA)
2001: Development
begins on HealtheVet
program
Source: CRS graphic based on information from the Department of Defense/Department of Veterans Affairs Interagency Program Office (IPO).
Notes: AHLTA= Armed Forces Health Longitudinal Technology Application
CRS-27
BHIE =Bidirectional Health Information Exchange
CHDR= Clinical Data Repository/Health Data Repository
DHCP= Decentralized Hospital Computer Program; precursor to the Veterans Health Information Systems and Technology Architecture(VistA)
DOD= Department of Defense
FHCC= Federal Health Care Center
FHIE= Federal Health Information Exchange
GCPR= Government Computer-Based Patient Record
LDSI =Laboratory Data Sharing Interface
MHS= Military Health System
VA= Department of Veterans Affairs
VistA =Veterans Health Information Systems and Technology Architecture
VHA= Veterans Health Administration
VLER =Virtual Lifetime Electronic Record
CRS-28
Departments of Defense and Veterans Affairs: Status of the iEHR
Author Contact Information
Sidath Viranga Panangala
Don J. Jansen
Specialist in Veterans Policy
Analyst in Defense Health Care Policy
spanangala@crs.loc.gov, 7-0623
djansen@crs.loc.gov, 7-4769
Acknowledgments
Michael Taylor, an intern in the Domestic Social Policy Division, provided research assistance for this
report.
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