Veterans Affairs: Posthearing Questions Concerning the Departments of Defense and Veterans Affairs Providing Seamless Health Care Coverage to Transitioning Veterans

Published by the Government Accountability Office on 2003-11-24.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

United States General Accounting Office
Washington, DC 20548

         November 24, 2003

         The Honorable Christopher H. Smith
         Committee on Veterans’ Affairs
         House of Representatives

         Subject: Veterans Affairs: Posthearing Questions Concerning the Departments of
         Defense and Veterans Affairs Providing Seamless Health Care Coverage to
         Transitioning Veterans

         Dear Mr. Chairman:

         On October 16, 2003, I testified before your Subcommittee at a hearing on Hand-off or
         Fumble: Are DOD and VA Providing Seamless Health Care Coverage to Transitioning
         Veterans?1 This letter responds to your request that we provide answers to follow-up
         questions from the hearing. Your questions, along with my responses, follow.

         1. “GAO, at the request of this Committee, has examined VA’s Information
         Technology (IT) needs a number of times. Also, GAO has studied DOD’s IT
         infrastructure. VA and DOD have pledged over the years to be working toward
         common solutions to their IT challenges, most particularly in the area of
         computerized patient care records and the portability of these records across the
         several systems involved. Yet, they soldier on separately. What are the basic
         problems in the view of GAO, that prevent or obstruct the accomplishment of this
         goal of a single patient care record that can accompany a military servicemember
         from active duty to veteran status?”

         Answer: VA and DOD have been pursuing ways to share data in their health information
         systems and create electronic records since 1998, when the Government Computer-Based
         Patient Record (GCPR) project was initiated. GCPR was envisioned as an electronic
         interface that would allow physicians and other authorized users at VA, DOD, and Indian
         Health Service (IHS) health facilities to access data from any of the other agencies’ health
         facilities. The interface was expected to compile requested patient information in a
         “virtual” record that could be displayed on a user’s computer screen.

         U.S. General Accounting Office, Defense Health Care: DOD Needs to Improve Force Health Protection
         And Surveillance Processes, GAO-04-158T (Washington, D.C.: Oct. 16, 2003).

         The Indian Health Service became involved in GCPR because of its expertise in population-based research
         and its longstanding relationship with VA in caring for the American Indian veteran population.

Page 1                                                                   GAO-04-292R Defense Health Care
         Since undertaking this mission, however, VA and DOD have faced considerable
         challenges, leading to repeated changes in the focus of their initiative and the target dates
         for its accomplishment. Our prior reports discussing the initiative noted disappointing
         progress, exacerbated in large part by inadequate accountability and poor planning and
         oversight, which raised doubts about the departments’ ability to achieve an electronic
         interface among their health information systems. When we reported on the initiative in
         September 2002,4 VA and DOD had taken some actions aimed at strengthening their joint
         efforts. For example, they had clarified key roles and responsibilities for the initiative and
         begun executing revised near- and long-term strategies for achieving the electronic
         information exchange capability.

         The near-term initiative—the Federal Health Information Exchange—was completed in
         July 2002 and enabled the one-way transfer of data from DOD’s existing health care
         information system to a separate database that VA hospitals could access. This initiative
         has shown success in allowing clinicians in VA medical centers ready access to
         information—such as laboratory, pharmacy, and radiology records—on almost 2 million

         However, the departments’ strategy for an envisioned longer-term, two-way exchange of
         clinical information is farther out on the horizon. This initiative, HealthePeople (Federal),
         is premised upon the departments’ development of a common health information
         infrastructure and architecture comprising standardized data, communications, security,
         and high-performance health information systems. VA and DOD anticipated achieving a
         limited capability for two-way data exchange by the end of 2005.

         Nonetheless, VA and DOD continue to face significant challenges in realizing this longer-
         term capability. While the departments have developed a high-level strategy for the
         initiative, they face the challenge of clearly articulating a common health information
         infrastructure and architecture to show how they intend to achieve the data exchange
         capability or what exactly they will be able to exchange. Such an architecture is necessary
         for ensuring that the departments have defined a level of detail and specificity needed to
         build the exchange capability, including requirements and design specifications.

         In addition, critical to the two-way exchange will be completing the standardization of the
         clinical data that these departments plan to share. Data standardization is essential to
         allowing the exchange of health information from disparate systems and improving
         decision-making by providing health information when and where it is needed. Currently,
         VA and DOD face an enormous task of standardizing their health data. VA will have to
         migrate over 150 variations of clinical and demographic data to one standard, and DOD
         will have to migrate over 100 variations of clinical data to one standard. VA and DOD
         officials maintain that their departments, along with the Department of Health and Human
         Services, are actively pursuing the development and adoption of data standards.
         Nonetheless, they remain uncertain as to when the necessary standardization will be

         U.S. General Accounting Office, Computer-Based Patient Records: Better Planning and Oversight by VA,
         DOD, and IHS [Indian Health Service] Would Enhance Health Data Sharing, GAO-01-459 (Washington,
         D.C.: Apr. 30, 2001); VA Information Technology: Progress Made, but Continued Management Attention Is
         Key to Achieving Results, GAO-02-369T (Washington, D.C.: Mar. 13, 2002); and VA Information Technology:
         Management Making Important Progress in Addressing Key Challenges GAO-02-1054T (Washington, D.C.:
         Sept. 26, 2002).
Page 2                                                                  GAO-04-292R Defense Health Care
         accomplished. Without standardization, the task of sharing meaningful data is made more
         complex and may not prove successful.

         2. “Assuming that VA and DOD actually unify their patient care record keeping,
         will this accomplishment solve the “seamless transition” challenge, or will the
         records problem be supplanted by some other new one, such as HIPAA [Health
         Insurance Portability and Accountability Act] or another cause, and what are
         your reasons for this conclusion?”

         Answer: Achieving the technical capability to unify VA’s and DOD’s patient care records
         in and of itself will not ensure the seamless transition of health care data. Other issues that
         the departments need to address include the following:

         •   Reaching consensus on and implementing data standards. As we pointed out in our
             previous response, an essential aspect of making the data usable will be establishing
             data standards. Accomplishing this is particularly challenging, as consensus must be
             reached with clinicians and other health care providers to achieve common acceptance
             of the standards.

         •   Capturing complete and accurate medical information on service members. The
             departments must establish and closely adhere to a process that will ensure the
             complete and accurate capture of medical information of service members stored in
             their respective databases. As noted in our testimony, DOD’s database does not
             currently contain patient health information (such as health assessments and
             immunizations) for all service members.

         •   Ensuring privacy and security compliance. The departments will have to ensure that
             the exchange of medical information is compliant with privacy requirements
             established in the HIPAA. In addition, given the sensitivity of patient health
             information, the departments must ensure that adequate security is an integral feature
             of the data exchange capability.

                                                                    -- -- -- -- --

         We are sending copies of this letter to the Secretary of Veterans Affairs and the Secretary
         of Defense and other interested parties. We will also make copies available to others upon
         request. In addition, this report will be available at no charge on the GAO Web site at
         http://www.gao.gov. Should you or your staff have any questions on matters discussed in
         this letter, please contact me at (757) 552-8100. I can also be reached by e-mail at

         Sincerely yours,

         Neal P. Curtin
         Director, Operations and Readiness Issues


          VA and DOD plan to implement a capability to share patient health information that will be collected in data
         repositories that each is implementing.
Page 3                                                                      GAO-04-292R Defense Health Care
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