Healthcare information technology systems used by the Military Health System at the Defense Department and the Veterans Health Administration at the Veterans Affairs Department still have not achieved full interoperability after a decade of trying, the Government Accountability Office reports.
In addition, the two departments don’t yet have up and running a congressionally mandated office to oversee development of the long-delayed healthcare information exchange capabilities, the GAO said. The lack of a central office for the job put the Defense Department and the VA at risk of not meeting a September 2009 congressional deadline for achieving interoperability.
The congressional watchdog, however, did give the Defense Department and VA some credit for progress made.
If the “We’re still working on it” refrain sounds familiar, that is because the GAO has said much the same thing in a dozen prior reports since 2001 on what has been a very slow road to interoperability between the two healthcare agencies. The Defense Department and VA “have been working to exchange patient health data electronically since 1998,” the GAO said.
The GAO report notes that in 2003, a presidential task force recommended that the Defense Department and VA develop a system of bidirectional data exchange by 2005, but by 2007, a presidential commission on care for wounded veterans reported that the two departments had continued to develop “independent, stand-alone systems.”
The most recent, 45-page GAO report
, Electronic Health Records: DoD and VA Have Increased Their Sharing of Health Information, but More Work Remains
was the first of a series of biannual reports Congress required the government watchdog to release under the National Defense Authorization Act for Fiscal Year 2008.
The law also requires the departments to set up a joint office to create a single point of accountability for the data-exchange effort, a recommendation the GAO had made previously. Finally, it set a Sept. 30, 2009 target date for “full interoperability of personal healthcare information between the two departments,” the GAO said.
In preparation for the report, the GAO researchers interviewed officials from the departments as well as the Office of the National Coordinator for Health Information Technology at HHS and visited 256-bed Walter Reed Army Medical Center and the 291-bed Veterans Affairs Medical Center, Washington, all between March and July this year.
“The departments’ effort to set up the program office is still in its early stages,” according to the GAO. “Leadership positions in the office are not yet permanently filled, staffing is not complete and facilities to house the office have not been designated.” In addition, an implementation plan remains in draft stage. And while the plan does contain some milestones—another persistent GAO recommendation—completion dates for some activities have not been set, the report said.
Part of the difficulty in achieving interoperability is because of the historically different approaches taken by the departments, the GAO report said.
The VA “has one integrated medical information system—the Veterans Health Information Systems and Technology Architecture, or VistA—which uses all electronic records and was developed in-house by VA clinicians and IT personnel. All VA medical facilities have access to all VistA information.”
In contrast, the GAO said, “the DoD uses multiple legacy medical-information systems, all of which are commercial software products that are customized for specific uses. Until recently, those systems could not share information. In addition, not all of DoD’s medical information is electronic: Certain records are paper-based."
The GAO noted that the Defense Department's Composite Health Care System, or CHCS I—which was developed by a private contractor, SAIC, based on the VA's clinical IT system but lost interoperability with the VA in the process—is used by Military Health System facilities to capture pharmacy, radiology and laboratory information. The Defense Department also uses a modified, commercial clinical information system at some inpatient facilities, an integrated clinical database at some Air Force facilities and a Theater Medical Data Store in combat areas and to move medical records while transferring patients from one location to another. The military is attempting to replace CHCS I with a new system, now called AHLTA, but formerly known as the Armed Forces Health Longitudinal Technology Application and before that, CHCS II.
Despite these interfacing hurdles, the departments have had some success stories, according to the GAO, including the Federal Health Information Exchange, which dates to 2004 and allows the Defense Department to ship the medical records of military personnel leaving active duty to the VA. Laboratory Data Sharing Interface, also from 2004, has been deployed at nine sites and allows the cross-communication of laboratory test orders and results, the GAO said. Finally, the GAO mentions the Bidirectional Health Information Exchange, again from 2004, which allows clinicians from both departments to view the medical records of “shared” patients, who, for example, may receive care from VA physicians while hospitalized at a military treatment facility.
The departments are looking to develop a two-way exchange between AHLTA and the VA’s VistA successor system, HealtheVet, through linked clinical data stores, the Defense Department’s Clinical Data Repository and the VA’s Health Data Repository. The GAO notes that project, called CHDR, which was launched in 2004, was implemented at one site in September 2006.
“Beyond these initiatives,” the GAO said, “in January 2007, the departments announced a further change to their information-sharing strategy: their intention to jointly determine an approach for inpatient health records.” On July 31, 2007, the departments awarded a contract to Booz Allen Hamilton for a feasibility study as well as an exploration of alternatives.
The GAO said “one of the options would be adopting a joint solution, which would be expected to facilitate the seamless transition of active-duty service members to veteran status, and make inpatient healthcare data on shared patients more readily accessible to both DoD and VA. In addition, the departments believe that a joint development effort could enable them to realize cost savings; however, no decision on a joint system has yet been made. According to the departments, they expect to receive recommendations on possible approaches at the end of July 2008.”
The report has been received, according to Josephine Schuda, a VA spokeswoman, but it is not yet available for public inspection.
“It’s in government review,” Schuda said. A presentation is being prepared based on the study’s recommendations to VA and Defense Department senior leadership, she said.
Meanwhile, the Military Health System is getting internal pressure from its own clinicians to fix AHLTA, a system that its users complain
is often slow and undependable.
Retired Lt. Gen. James Peake, secretary of Veterans Affairs and a veteran of the Army and the Medical Corps, responded in a letter attached to the GAO report that he agreed with the GAO’s conclusions and supported its recommendations, as did S. Ward Casscells, the assistant secretary of defense for health affairs who heads the Military Health System.
An acting director of the Interagency Program Office from the Defense Department and an acting deputy director from the VA were appointed in April, according to comments from the VA enclosed within the GAO report.
Peake said in his letter that he expects to have a permanent deputy director for the Interagency Program Office appointed by October and a permanent staff hired by December. A draft implementation plan was submitted to Congress in April and a Joint Clinical Information Board has been formed “to ensure that clinicians treating patients determine the key information that must be interoperable by September 2009.”
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