Electronic Health Records: VA and DOD Need to Support Cost and Schedule Claims, Develop Interoperability Plans, and Improve Collaboration
Highlights
What GAO Found
The Departments of Veterans Affairs (VA) and Defense (DOD) abandoned their plans to develop an integrated electronic health record (iEHR) system and are instead pursuing separate efforts to modernize or replace their existing systems in an attempt to create an interoperable electronic health record. Specifically, in February 2013, the secretaries cited challenges in the cost and schedule for developing the single, integrated system and announced that each department would focus instead on either building or acquiring similar core sets of electronic health record capabilities, then ensuring interoperability between them. However, VA and DOD have not substantiated their claims that the current approach will be less expensive and more timely than the single-system approach. Major investment decisions—including terminating or significantly restructuring an ongoing program—should be justified using analyses that compare the costs and schedules of alternative proposals. Yet, the departments have not developed revised cost and schedule estimates for their new modernization efforts and any additional efforts needed to achieve interoperability between the new systems, and compared them with the relevant estimates for their former approach. In the absence of such a comparison, VA and DOD lack assurance that they are pursuing the most cost-effective and timely course of action for delivering the fully interoperable electronic health record the departments have long pursued to provide the best possible care for service members and veterans.
The departments have initiated their separate system efforts. VA intends to deploy clinical capabilities of its new system at two locations by September 2014, and DOD has set a goal of beginning deployment of its new system by the end of fiscal year 2016. However, the departments have yet to update their joint strategic plan to reflect the new approach or to disclose what the interoperable electronic health record will consist of, as well as how, when, and at what cost it will be achieved. Without plans that include the scope, lines of responsibility, resource requirements, and an estimated schedule for achieving an interoperable health record, VA, DOD, and their stakeholders may not have a shared understanding of how the departments intend to address their common health care business needs.
VA and DOD have not addressed management barriers to effective collaboration on their joint health information technology (IT) efforts. As GAO previously reported, the departments faced barriers to effective collaboration in the areas of enterprise architecture and IT investment management, among others. However, they have yet to address these barriers by, for example, developing a joint health care architecture or a joint IT investment management process to guide their collaboration. Further, the Interagency Program Office (IPO), established by law to act as a single point of accountability for the departments' development of interoperable health records, was to better position the departments to collaborate; but the departments have not implemented the IPO in a manner consistent with effective collaboration. For example, the IPO lacks effective control over essential resources such as funding and staffing. In addition, recent decisions by the departments have diffused responsibility for achieving integrated health records, potentially undermining the IPO's intended role as the point of accountability. Providing the IPO with control over essential resources and clearer lines of authority would better position it for effective collaboration.
Why GAO Did This Study
VA and DOD operate two of the nation's largest health care systems, serving approximately 16 million veterans and active duty service members, and their beneficiaries, at total annual costs of over $100 billion. The departments have recognized the importance of developing capabilities for sharing electronic patient health information and have worked since 1998 to develop such capabilities. In February 2011, VA and DOD initiated a program to develop a single, common electronic health record system—iEHR—to replace their existing health record systems. This program was to be managed by the IPO and implemented by 2017. However, the departments made significant changes to the program in 2013. GAO was asked to review the iEHR program. This report (1) describes changes to the program and evaluates the departments' current plans and (2) determines whether the departments are effectively collaborating on management of the program. GAO reviewed relevant program documents and interviewed agency officials.
Recommendations
GAO recommends that VA and DOD develop and compare the estimated cost and schedule of their current and previous approaches to creating an interoperable electronic health record and, if applicable, provide a rationale for pursuing a more costly or time-consuming approach. GAO also recommends that the departments develop plans for interoperability and ensure the IPO has control over needed resources and clearer lines of authority. VA and DOD concurred with GAO's recommendations.
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Department of Defense | To bring transparency and credibility to the Secretaries of Veterans Affairs and Defense's assertion that VA and DOD's current approach to achieving an interoperable electronic health record will cost less and take less time than the previous single-system approach, the secretaries should (1) develop a cost and schedule estimate for their current approach, from the perspective of both departments, that includes the estimated cost and schedule of VA's VistA Evolution program, DOD's DOD Healthcare Management System Modernization (DHMSM) program, and the departments' joint efforts to achieve interoperability between the two systems; then, (2) compare the cost and schedule estimates of the departments' current and previous (i.e., single-system) approaches. If the results of the comparison indicate that the departments' current approach is estimated to cost more and/or take longer than the single-system approach, the secretaries should (1) provide a rationale for pursuing the current approach despite its higher cost and/or longer schedule and (2) report the cost and schedule estimates of the current and previous approaches, results of the comparison of the estimates, and reasons (if applicable) for pursuing a more costly or time-consuming approach to VA's and DOD's congressional authorizing and appropriations committees. |
DOD concurred with and took steps that were partially responsive to GAO's February 2014 recommendation. Specifically, as of March 2017, DOD had developed cost and schedule estimates for its ongoing electronic health record system modernization effort, although the department had not provided comparisons between these and previous estimates. However, DOD and VA now plan to use the same commercially available electronic health record system as a result of the Secretary of Veterans Affairs' June 2017 decision that his department will acquire the same system that DOD is currently implementing. In light of these actions, we believe the steps DOD has taken are sufficient to address this recommendation and mitigate the need for the department to compare its current and previous electronic health record system modernization cost and schedule estimates.
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| Department of Veterans Affairs | To bring transparency and credibility to the Secretaries of Veterans Affairs and Defense's assertion that VA and DOD's current approach to achieving an interoperable electronic health record will cost less and take less time than the previous single-system approach, the secretaries should (1) develop a cost and schedule estimate for their current approach, from the perspective of both departments, that includes the estimated cost and schedule of VA's VistA Evolution program, DOD's DOD Healthcare Management System Modernization (DHMSM) program, and the departments' joint efforts to achieve interoperability between the two systems; then, (2) compare the cost and schedule estimates of the departments' current and previous (i.e., single-system) approaches. If the results of the comparison indicate that the departments' current approach is estimated to cost more and/or take longer than the single-system approach, the secretaries should (1) provide a rationale for pursuing the current approach despite its higher cost and/or longer schedule and (2) report the cost and schedule estimates of the current and previous approaches, results of the comparison of the estimates, and reasons (if applicable) for pursuing a more costly or time-consuming approach to VA's and DOD's congressional authorizing and appropriations committees. |
VA concurred with and took steps that were partially responsive to GAO's February 2014 recommendation. Specifically, as of March 2017, VA had developed cost and schedule estimates for its electronic health record system modernization effort, although the department had not provided comparisons between these and previous estimates. However, in June 2017, the Secretary of Veterans Affairs announced that, rather than continue to modernize the department's existing system, VA plans to acquire the same commercially available electronic health record system that DOD is currently implementing. In light of VA's plan, we believe the actions the department has taken are sufficient to address this recommendation and mitigate the need for comparison between cost and schedule estimates for electronic health record system modernization approaches that the department is no longer pursuing.
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| Department of Defense | To better position VA and DOD to achieve an interoperable electronic health record, the Secretaries of Veterans Affairs and Defense should develop a plan that, at a minimum, describes (1) the clinical domains that the interoperable electronic health record will address; (2) a schedule for implementing the interoperable record at each VA and DOD location; (3) the estimated cost of each major component (i.e., VistA Evolution, DHMSM, etc.) and the total cost of the departments' interoperability efforts; (4) the organizations within VA and DOD that are involved in acquiring, developing, and implementing the record, as well as the roles and responsibilities of these organizations; (5) major risks to the departments' interoperability efforts and mitigation plans for those risks; and (6) the departments' approach to defining, measuring, tracking, and reporting progress toward achieving expected performance (i.e., benefits and results) of the interoperable record. |
As of March 2017, DOD had taken actions to address GAO's February 2014 recommendation that it develop a plan for achieving an interoperable electronic health record with VA. For example, DOD, in conjunction with VA, developed a Joint Interoperability Plan that referred to the Interagency Program Office's Healthcare Information Interoperability Technical Package, which identified a list of clinical domains to be included in the interoperable electronic health record. The plan also included expected dates for key interoperability activities, as well as high-level risks that may challenge the departments' efforts to promote interoperability, and mitigation plans for those risks. The plan, together with the Health Data Interoperability Management Plan, described the organizations within DOD that are to be involved in acquiring, developing, and implementing the electronic health record. Additionally, the Joint Interoperability Plan, along with the Interoperability Milestones and Metrics document, included high-level descriptions of monitoring and performance testing and specific goals and metrics related to defining, measuring, tracking, and reporting progress toward achieving expected performance of interoperable records. Lastly, DOD has performed multiple iterations of cost estimates for its system modernization.
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| Department of Veterans Affairs | To better position VA and DOD to achieve an interoperable electronic health record, the Secretaries of Veterans Affairs and Defense should develop a plan that, at a minimum, describes (1) the clinical domains that the interoperable electronic health record will address; (2) a schedule for implementing the interoperable record at each VA and DOD location; (3) the estimated cost of each major component (i.e., VistA Evolution, DHMSM, etc.) and the total cost of the departments' interoperability efforts; (4) the organizations within VA and DOD that are involved in acquiring, developing, and implementing the record, as well as the roles and responsibilities of these organizations; (5) major risks to the departments' interoperability efforts and mitigation plans for those risks; and (6) the departments' approach to defining, measuring, tracking, and reporting progress toward achieving expected performance (i.e., benefits and results) of the interoperable record. |
As of March 2017, VA had taken actions to address GAO's February 2014 recommendation that it develop a plan for achieving an interoperable electronic health record with DOD. For example, VA, in conjunction with DOD, developed a Joint Interoperability Plan that referred to the Interagency Program Office's Healthcare Information Interoperability Technical Package, which identified a list of clinical domains to be included in the interoperable electronic health record. The plan also included expected dates for key interoperability activities, as well as high-level risks that may challenge the departments' efforts to promote interoperability, and mitigation plans for those risks. The plan, together with the Health Data Interoperability Management Plan, described the organizations within VA that are to be involved in acquiring, developing, and implementing the electronic health record. Additionally, the Joint Interoperability Plan, along with VA's Interoperability Milestones and Metrics document, included high-level descriptions of monitoring and performance testing and specific goals and metrics related to defining, measuring, tracking, and reporting progress toward achieving expected performance of interoperable records. Lastly, VA has performed multiple iterations of cost estimates for its system modernization.
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| Department of Defense | To better position the Interagency Program Office for effective collaboration between VA and DOD and to efficiently and effectively fulfill the office's stated purpose of functioning as the single point of accountability for achieving interoperability between the departments' electronic health record systems, the Secretaries of Veterans Affairs and Defense should ensure that the IPO has authority (1) over dedicated resources (e.g., budget and staff), (2) to develop interagency processes, and (3) to make decisions over the departments' interoperability efforts. |
DOD concurred with GAO's February 2014 recommendation and asserted that the IPO, which was re-chartered in December 2013, remained the single point of accountability for achieving interoperability between the DOD's and VA's electronic health record systems. However, since GAO made its recommendation in February 2014, the departments have pursued separate approaches to modernizing their respective electronic health record systems and have established governance structures that are independent of the IPO to manage their efforts. Specifically, DOD has established the Program Executive Office for Defense Health Management Systems, which manages multiple programs related to the department's interoperability efforts, including DOD's acquisition of a new electronic health record system. Additionally, the IPO was again re-chartered in May 2016 with a new purpose--to jointly oversee and monitor, and be the single point of accountability, the efforts of the departments in implementing national health data standards for interoperability. This new purpose does not refer to the IPO's previous responsibility as the single point of accountability for achieving interoperability between the departments' electronic health record systems. Thus, the IPO's role as a vehicle for promoting effective collaboration between the departments is diminished and GAO is no longer assessing this action.
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| Department of Veterans Affairs | To better position the Interagency Program Office for effective collaboration between VA and DOD and to efficiently and effectively fulfill the office's stated purpose of functioning as the single point of accountability for achieving interoperability between the departments' electronic health record systems, the Secretaries of Veterans Affairs and Defense should ensure that the IPO has authority (1) over dedicated resources (e.g., budget and staff), (2) to develop interagency processes, and (3) to make decisions over the departments' interoperability efforts. |
VA concurred with GAO's February 2014 recommendation and asserted that the IPO, which was re-chartered in December 2013, remained the single point of accountability for achieving interoperability between VA's and DOD's electronic health record systems. However, since GAO made its recommendation in February 2014, VA has pursued a separate approach to modernizing its electronic health record system and has established a governance structure that is independent of the IPO to manage its efforts. VA established the Executive Triad of VA officials under the Chief Information Officer to oversee modernizing its electronic health record system, which is managed jointly by the Office of Information and Technology and the Veterans Health Administration. Additionally, the IPO was again re-chartered in May 2016 with a new purpose--to jointly oversee and monitor, and be the single point of accountability, the efforts of the departments in implementing national health data standards for interoperability. This new purpose does not refer to the IPO's previous responsibility as the single point of accountability for achieving interoperability between the departments' electronic health record systems. Thus, the IPO's role as a vehicle for promoting effective collaboration between the departments is diminished and GAO is no longer assessing this action.
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