Outcome-Oriented Metrics and Goals Needed to Gauge DOD's and VA's Progress in Ach

38 Pages·2015·2.56 MB·English

United States Government Accountability Office

Report to Congressional Committees

August 2015 ELECTRONIC

HEALTH RECORDS
Outcome-Oriented
Metrics and Goals
Needed to Gauge
DOD’s and VA’s
Progress in Achieving
Interoperability

GAO-15-530
August 2015
ELECTRONIC HEALTH RECORDS
Outcome-Oriented Metrics and Goals Needed to
Gauge DOD’s and VA’s Progress in Achieving
Interoperability
Highlights of GAO-15-530, a report to
congressional committees
Why GAO Did This Study What GAO Found
DOD and VA operate two of the The Departments of Defense (DOD) and Veterans Affairs (VA), with guidance
nation’s largest health care systems, from the Interagency Program Office (IPO) that is tasked with facilitating the
serving approximately 16 million departments’ efforts to share health information, have taken actions to increase
veterans and active duty service interoperability between their electronic health record systems. Among other
members and their beneficiaries, at a things, DOD and VA have initiated work focused on near-term objectives,
cost of more than $100 billion a year. including standardizing their existing health data and making them viewable by
For almost two decades, the
both departments’ clinicians in an integrated format. The departments also have
departments have been engaged in
developed longer-term plans to modernize their respective electronic health
various efforts to advance DOD and
record systems. For its part, the IPO has issued guidance outlining the technical
VA electronic health record
approach for achieving interoperability between the departments’ systems.
interoperability. Among their most
recent efforts, the DOD and VA Even with the actions taken, DOD and VA did not, by the October 1, 2014,
Secretaries have committed the deadline established in the National Defense Authorization Act (NDAA) for Fiscal
departments to achieving Year 2014 for compliance with national data standards, certify that all health care
interoperability between their separate data in their systems complied with national standards and were computable in
electronic health record systems.
real time. Both departments stated that they intend to do so later in calendar year
The Consolidated Appropriations Act, 2015. Further, the departments’ system modernization plans identify a number of
2014, and accompanying Joint key activities to be implemented beyond December 31, 2016—the deadline
Explanatory Statement, included a established in the NDAA for the two departments to deploy modernized
provision for GAO to review the electronic health record software to support clinicians while ensuring full
departments’ efforts. GAO evaluated standards-based interoperability. Specifically, DOD has issued plans and
the actions taken by DOD, VA, and the announced the contract award for acquiring a modernized system to include
IPO to plan for and measure the interoperability capabilities across military operations. In addition, VA has issued
progress toward achieving plans describing an incremental approach to modernizing its existing electronic
interoperability between the health records system. These plans—if implemented as currently described—
departments’ electronic health record indicate that deployment of the new systems with interoperability capabilities will
systems. GAO reviewed relevant
not be completed across the departments until after 2018.
program documents and interviewed
agency officials. The IPO has taken steps to develop process metrics intended to monitor
progress related to the data standardization and exchange of health information
What GAO Recommends
consistent with its responsibilities. For example, it has issued guidance that calls
GAO recommends that DOD and VA, for tracking metrics, such as the percentage of data domains within the
working with the IPO, establish a time departments’ current health information systems that are mapped to national
frame for identifying outcome-oriented standards. However, the office has not yet specified outcome-oriented metrics
metrics; define related goals to provide and established related goals that are important to gauging the impact that
a basis for assessing and reporting on interoperability capabilities have on improving health care services for shared
the status of interoperability; and patients. IPO officials said this work is ongoing and that a team is working with
update IPO guidance to reflect the DOD, VA, and subject matter experts to identify metrics that would provide more
metrics and goals identified. DOD and meaningful measures of the impact of increased interoperability. However, the
VA concurred with GAO’s IPO has not identified a time frame for when this team will report its results and
recommendations. when the IPO plans to incorporate these metrics and goals into its guidance.
Without ensuring that outcome-oriented metrics and related goals are defined
and incorporated into the current approach, the departments and the IPO will not
be positioned to assess and report on the status of interoperability-related
activities and determine areas that need improvement.
View GAO-15-530. For more information,

contact Valerie C. Melvin at [phone] or
[email protected].
United States Government Accountability Office
Contents

Letter 1
Background 3
DOD, VA, and the IPO Have Taken Steps toward Achieving
Interoperability, but All Key Activities Will Not Be Completed
until Future Years, and Plans Lack Outcome-Oriented Metrics
and Goals 12
Conclusions 20
Recommendations for Executive Action 21
Agency Comments and Our Evaluation 21
Appendix I Objective, Scope, and Methodology 25

Appendix II Comments from the Department of Veterans Affairs 27

Appendix III Comments from the Department of Defense 30

Appendix IV GAO Contact and Staff Acknowledgments 33

Table
Table 1: History of Interoperability Initiatives between DOD and
VA 7

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Abbreviations

AHLTA Armed Forces Health Longitudinal Technology Application
CHCS Composite Health Care System
DHMSM Defense Healthcare Management System Modernization
DOD Department of Defense
iEHR Integrated Electronic Health Record
IPO Interagency Program Office
IT information technology
NDAA National Defense Authorization Act
ONC Office of the National Coordinator for Health Information
Technology
SNOMED CT Systematized Nomenclature of Medicine Clinical Terms
VA Department of Veterans Affairs
VistA Veterans Health Information Systems and Technology
Architecture

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Page ii GAO-15-530 Electronic Health Records
Letter

441 G St. N.W.
Washington, DC 20548
August 13, 2015
Congressional Committees
The Department of Defense (DOD) and the Department of Veterans
Affairs (VA) operate two of the nation’s largest health care systems,
providing care to approximately 6.3 million veterans and 9.6 million active
duty service members and their beneficiaries at estimated annual costs of
about $53 billion and $49 billion, respectively. Among these are more
than 5 million shared patients who receive health care and services from
both departments.
DOD and VA have long recognized the importance of electronic health
records as an essential part of delivering quality care to veterans and
service members. Thus, for almost two decades, the departments have
been engaged in various efforts to advance electronic health record
interoperability—intended to provide seamless sharing of health care data
and make patient information more readily available to health care
providers, reduce medical errors, and streamline administrative
functions.1
Among their most recent efforts, the departments have stated that they
plan to rely on separate systems to achieve an interoperable electronic
health record. Toward this end, DOD is undertaking the procurement of a
new electronic health record system as part of the Defense Healthcare
Management System Modernization (DHMSM) program, whereas VA
plans to evolve and modernize its existing system as part of its Veterans
Health Information Systems and Technology Architecture (VistA)
Evolution program. The DOD/VA Interagency Program Office (IPO)2 is
currently chartered and tasked to facilitate the departments’ efforts by
identifying interoperability standards and coordinating activities to
increase the sharing of health information between the two systems.

1For example, the National Defense Authorization Act (NDAA) for Fiscal Year 2008, Pub.
L. No. 110-181, § 1635, 122 Stat. 3, 460-463 (2008), called for DOD and VA to jointly
develop fully interoperable electronic health records systems or capabilities.
2The fiscal year 2008 NDAA also called for DOD and VA to set up an interagency program
office, which was to be a single point of accountability for their efforts to implement these
systems or capabilities.
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In light of the departments’ not having yet implemented a solution that
allows for seamless electronic sharing of medical health care data, the
National Defense Authorization Act (NDAA) for Fiscal Year 20143
included requirements pertaining to the implementation, design, and
planning for interoperability between DOD’s and VA’s electronic health
record systems. Among other things, the departments were each directed
to (1) ensure that all health care data contained in DOD’s Armed Forces
Health Longitudinal Technology Application (AHLTA) and VA’s VistA
systems complied with national standards and were computable in real
time by October 1, 2014, and (2) deploy modernized electronic health
record software to support clinicians while ensuring full standards-based
interoperability by December 31, 2016.
In addition, the Consolidated Appropriations Act, 20144 and the
accompanying Joint Explanatory Statement included a provision for GAO
to conduct a study of the two departments’ pursuit of interoperable
electronic health record systems. Our objective was to evaluate the
actions taken by DOD, VA, and the IPO to plan for and measure the
progress toward achieving interoperability between the departments’
electronic health record systems.
We obtained and reviewed relevant program documentation, including
IPO guidance documents, VistA Evolution planning documents, and
DOD’s DHMSM request for proposals. We analyzed these documents to
determine if the planned activities and milestones described therein were
consistent with requirements and time frames specified in the fiscal year
2014 NDAA. We also reviewed relevant documentation, such as the IPO
Health Data Interoperability Management Plan, to identify planned metrics
tracked and reported by the IPO. In addition, we reviewed reports, such
as the IPO Executive Committee quarterly reports and the DOD/VA
quarterly data sharing reports to Congress, to determine if metrics and
goals related to interoperability were consistent with GAO guidance that
discussed process and outcome metrics used for performance

3Pub. L. No. 113-66, Div. A, Title VII, § 713, 127 Stat. 672, 794-798 (Dec. 26, 2013).
4Pub. L. No. 113-76, 128 Stat. 5, Div. C, Title VI, 128 Stat. 101; Div. J, Title II, 128 Stat.
453 (Jan. 17, 2014).
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measurement.5 Further, we interviewed cognizant officials, such as the
IPO Acting Director, Deputy Director, and other DOD and VA program
officials to understand current efforts related to improving interoperability
between the departments. Appendix I describes our objectives, scope,
and methodology in greater detail.
We conducted this performance audit from September 2014 to August
2015 in accordance with generally accepted government auditing
standards. Those standards require that we plan and perform the audit to
obtain sufficient, appropriate evidence to provide a reasonable basis for
our findings and conclusions based on our audit objective. We believe
that the evidence obtained provides a reasonable basis for our findings
and conclusions based on our audit objective.

Historically, patient health information has been scattered across paper
Background
records kept by many different caregivers in many different locations,
making it difficult for a clinician to access all of a patient’s health
information at the time of care. Lacking access to these critical data, a
clinician may be challenged in making the most informed decisions on
treatment options, potentially putting the patient’s health at risk. The use
of technology to electronically collect, store, retrieve, and transfer clinical,
administrative, and financial health information has the potential to
improve the quality and efficiency of health care.
Electronic health records are particularly crucial for optimizing the health
care provided to military personnel and veterans. While in active military
status and later as veterans, many DOD and VA personnel, along with
their family members, tend to be highly mobile and may have health
records residing at multiple medical facilities within and outside the United
States.
Each department operates separate electronic health record systems that
they rely on to create and manage patient health information. In

5GAO, Electronic Health Record Programs: Participation Has Increased, but Action
Needed to Achieve Goals, Including Improved Quality of Care, GAO-14-207 (Washington,
D.C.: March 6, 2014); Designing Evaluations: 2012 Revision, GAO-12-208G (Washington,
D.C.: Jan. 31, 2012); Performance Measurement and Evaluation: Definitions and
Relationships, GAO-11-646SP (Washington, D.C.: May 2, 2011); and Executive Guide:
Effectively Implementing the Government Performance and Results Act,
GAO/GGD-96-118 (Washington, D.C.: June 1, 1996).
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particular, DOD currently relies on AHLTA, which comprises multiple
legacy medical information systems that were developed from
commercial software products and customized for specific uses. For
example, the Composite Health Care System (CHCS), which was
formerly DOD’s primary health information system, is used to capture
information related to pharmacy, radiology, and laboratory order
management. In addition, the department uses Essentris (also called the
Clinical Information System), a commercial health information system
customized to support inpatient treatment at military medical facilities.
For its part, VA currently uses its integrated medical information system—
VistA—which was developed in-house by VA clinicians and information
technology (IT) personnel. The system consists of 104 separate computer
applications, including 56 health provider applications; 19 management
and financial applications; 8 registration, enrollment, and eligibility
applications; 5 health data applications; and 3 information and education
applications.

Interoperability: An The sharing of health information among organizations is especially
Overview important because the health care system is highly fragmented, with care
and services provided in multiple settings, such as physician offices and
hospitals, that may not be able to coordinate patient medical care
records. Thus, a means for sharing information among providers, such as
between DOD’s and VA’s health care systems, is achieving
interoperability.
The Office of the National Coordinator for Health IT (ONC),6 within the
Department of Health and Human Services, has issued draft guidance,7
describing interoperability as:
1. the ability of systems to exchange electronic health information and

6ONC is responsible for overseeing the certification of electronic health record technology,
including establishing technical standards and certification criteria for it. Additionally, ONC
is charged with formulating the federal government’s health IT strategy and coordinating
related policies, programs, and investments.
7ONC, Connecting Health and Care for the Nation: A Shared Nationwide Interoperability
Roadmap DRAFT Version 1.0. The definition of interoperability used in the Roadmap is
derived from the Institute of Electrical and Electronics Engineers definition of
interoperability.
Page 4 GAO-15-530 Electronic Health Records
2. the ability to use the electronic health information that has been
exchanged from other systems without special effort on the part of the
user.
Similarly, the fiscal year 2014 NDAA defines interoperability, as used in
the provision governing the departments’ electronic health records, as
“the ability of different electronic health records systems or software to
meaningfully exchange information in real time and provide useful results
to one or more systems.” Thus, in these contexts, interoperability allows
patients’ electronic health information to be available from provider to
provider, regardless of where the information originated.
Achieving interoperability depends on, among other things, the use of
agreed-upon health data standards8 to ensure that information can be
shared and used. If electronic health records conform to interoperability
standards, they potentially can be created, managed, and consulted by
authorized clinicians and staff across more than one health care
organization, thus providing patients and their caregivers the information
needed for optimal care. Information that is electronically exchanged from
one provider to another must adhere to the same standards in order to be
interpreted and used in electronic health records, thereby permitting
interoperability.9 In the health IT field, standards may govern areas
ranging from technical issues, such as file types and interchange
systems, to content issues, such as medical terminology.10 On a national
level, ONC has been assigned responsibility for identifying health data
standards and technical specifications for electronic health record
technology and overseeing the certification of this technology.
In addition to exchanging the information, systems must be able to use
the information that is exchanged. Thus, electronic health record

8Health data standards are one component that can be used to facilitate health
information exchange and interoperability. Such standards consist of languages and
technical specifications that, when adopted by multiple entities, facilitate the exchange of
health information. Health data standards include, for example, standardized language for
prescriptions and for laboratory testing.
9GAO, Electronic Health Records: HHS Strategy to Address Information Exchange
Challenges Lacks Specific Prioritized Actions and Milestones, GAO-14-242 (Washington,
D.C.: March 24, 2014) and GAO-14-207.
10Developing, coordinating, and agreeing on standards are only parts of the processes
involved in achieving interoperability for electronic health records systems or capabilities.
In addition, specifications are needed for implementing the standards.
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technology has the potential to improve the quality of care that patients
receive and to reduce health care costs, if the technology is used in a way
that improves providers’ and patients’ access to critical information. For
example, with interoperability, medical providers have the ability to query
data from other sources while managing chronically ill patients,
regardless of geography or the network on which the data resides.11

DOD and VA Have a Long Since 1998, DOD and VA have relied on a patchwork of initiatives
History of Efforts to involving their health information systems to exchange information and to
increase electronic health record interoperability. These have included
Achieve Electronic Health
initiatives to share viewable data in existing (legacy) systems; link and
Record Interoperability
share computable data between the departments’ updated health data
repositories; develop a virtual lifetime electronic health record to enable
private sector interoperability; implement IT capabilities for the first joint
federal health care center; and jointly develop a single integrated system.
Table 1 provides a brief description of the history of these various
initiatives.

11ONC, Connecting Health and Care for the Nation: A Shared Nationwide Interoperability
Roadmap DRAFT Version 1.0.
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