Letter To The Honorable Gene L Dodaro, Comptroller General Of The United States
Letter
U.S. Senator Judd Gregg (R-NH) today sent a letter to initiate a Government Accountability Office (GAO) investigation into the quality and cost-effectiveness of health care delivery provided by the Department of Defense's health information technology (HIT) program. The Department of Veterans Affairs (VA) has developed an HIT system that has been widely praised for enabling reform of the VA health care system and improving safety and efficiency in veterans' health care. The success of this program has many independent and government HIT experts urging DOD to adopt the VA model as a means to improve the quality and cost-effectiveness of the military's health care system.
Senator Gregg stated, "Over the years, the Department of Defense has received an extraordinary level of funding to develop health information technology in an effort to deliver the best possible health care to members of our nation's military. Unfortunately, the current system in place is still not at the level it should be and results in delay, errors and other significant problems affecting both providers and beneficiaries. Given the clear and urgent need to improve health care delivery for our troops, we need a fair and impartial analysis of the current program to provide a basis for how we can improve care faster and at less cost. Our service members and veterans should not be forced to stand idly by while the government constructs a new system from scratch, especially if successful systems, such as the one developed by the VA, can improve the delivery of health care now."
The full text of the letter follows:
June 5, 2009
The Honorable Gene L Dodaro
Comptroller General of the United States
U.S. Government Accountability Office
441 G Street NW, Room 7125
Washington, DC 20548
Dear Mr. Dodaro:
As the Ranking Member of the Senate Budget Committee, and a member of the Subcommittee on Defense of the Senate Appropriations Committee, I am requesting that the Government Accountability Office investigate the Department of Defense's Armed Forces Health Longitudinal Technology Application (AHLTA) Program and provide analysis and recommendations for Congress to consider as it evaluates the President's Fiscal Year 2010 budget and Future Years Defense Plan.
AHLTA, the Military Health System's Electronic Health Record, has been under continuous development for more than a decade. The Department of Defense completed the world-wide deployment of AHLTA in December 2006; however, substantial concerns continue to be voiced by key user groups regarding the usability of the system, and its reliability, performance, and overall cost-effectiveness. The Military Health System recently announced a new strategy for AHLTA, known as the Unified Strategy Regional Distribution Approach, to address continuing procedural and performance concerns.
Separately, the Veterans Administration has developed and deployed its Veterans Health Information Systems and Technology Architecture (VistA), an enterprise-wide information system built around an Electronic Health Record, which has been widely praised for enabling reform of the VA healthcare system, and for improving safety and efficiency in veteran's healthcare. The success of VistA has led many independent, as well as government, information technology experts to propose that the Department of Defense adopt VistA as a means to improve quality of care, maximize cost effectiveness, and achieve interoperability between the health information technology systems of the Departments of Defense and Veterans Affairs.
Given the extraordinary level of funding that the Department of Defense has expended on AHLTA to date, the myriad ongoing concerns of providers and beneficiaries over the usability and performance of the system, recent procurement activities related to AHLTA by the Department of Defense that call into question the level of competition for, and engineering scrutiny associated with, new and substantial AHLTA-related investments, and the continuing success of the Veterans Administration's VistA program, there exists a clear and urgent need for a thorough, objective analysis of the AHLTA program.
Accordingly, I am requesting that the Government Accountability Office investigate the range of issues associated with AHLTA and provide to Congress a detailed summary of its conclusions and recommendations for achieving the requirements underpinning AHLTA. Specifically, I would ask that your analysis address the following issues:
**How much has been spent by the Department of Defense to date on development, deployment, sustainment, and modification of AHLTA? How much additional funding is being requested in the Future Years Defense Plan for AHLTA, and for what specific purposes? How does this future funding, along with current milestone schedules and related activity compare and contrast with previous budget justifications, hearing testimony, and other related statements from Executive Branch personnel regarding AHLTA costs and schedules?
** Is the Department of Defense providing appropriate engineering process management and scrutiny for an acquisition program this large and complex, as compared to other major defense acquisition programs?
**Has the Department of Defense issued sole source contracts, without competition, for key elements of AHLTA or its architectural planning and, if so, for what purposes and based on what level of competence, healthcare experience, and past performance were the awards justified? Has the Department of Defense made product selections for functional and architectural solutions without first conducting pilot efforts or competitive "fly offs" to validate selections? Have these actions created additional risk for the program?
**Military Health Service physicians have consistently expressed dissatisfaction with the "usability" of AHLTA, as well as its reliability. The Department of Veterans Affairs seems to have solved its own usability issues by building a "Clinical Viewer," known as the Computerized Patient Record System (CPRS), which leverages core VistA technology and reportedly makes the system much easier for physicians to utilize. Given that the Department of Defense's Composite Healthcare System was originally based on VistA, should the Department of Defense be considering a similar approach?
**Please describe the process currently in place within the Department of Defense to capture user and patient feedback on AHLTA, and describe how that input is analyzed and utilized by the Department to develop a more effective system. Are there ways to more effectively foster and apply user feedback?
**Would a framework that applies more rigorous engineering process oversight, and emphasizes selectively modernizing and/or replacing heritage functions in an incremental, evolutionary manner, represent a more cost and operationally effective approach? Why?
**Booz Allen Hamilton recently reported that the requirements in both the Departments of Defense and Veterans Affairs for a common Electronic Health Record were about a 96% match. Given this commonality and the imperative to enhance interoperability between the two Department's health information technology systems, and mindful of the demonstrated success of VistA in both Patient Care and Provider Acceptance, should the Department of Defense adopt VistA or a similar approach? Please explain your conclusions as to why the Department of Defense should or should not select either (1) the proven, successful government-owned VistA system or (2) a successful commercial-off-the-shelf (COTS) Electronic Health Record as opposed to the current AHLTA.
**Is the Department of Defense embarked on a path to build another Electronic Health Record from scratch?
**The Department of Defense is said to be focusing on "Open Source" software as a key solution to AHLTA's shortcomings. However, Open Source software, by its very nature, requires a significant amount of work to implement and self-support over time due to the lack of accountability for the supplier. Should Open Source software solutions be subject to the same set of requirements as other software that is procured by the U.S. government in other areas? Is an Open Source approach contrary to the principle of evaluating industry leading approaches that can leverage "lessons learned" in the private sector and bring positive solutions from private industry to the federal space?
Thank you for your assistance with this request. Given the highly complex, technical nature of this set of issues, and the limited technical expertise resident within the Congress, the Government Accountability Office is uniquely qualified to provide objective analysis and recommendations to help the House and Senate make informed oversight, policy, and funding decisions. Please feel free to coordinate with my Legislative Assistant, Brian Miller, at 202-224-3324 with any questions or followup.
Sincerely,
Judd Gregg
U.S. Senator
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