Opportunities Exist to Improve Management of DOD's Electronic Health Record Initiative

The Department of Defense (DOD) provides medical care to 9.6 million active duty service members, their families, and other eligible beneficiaries worldwide. DOD's Military Health System has long been engaged in efforts to acquire and deploy an electronic health record system. The latest version of this initiative--the Armed Forces Health Longitudinal Technology Application (AHLTA)--was expected to give health care providers real-time access to individual and military population health information and facilitate clinical support. However, the system's early performance was problematic, and DOD recently stated that it intended to acquire a new electronic health record system. GAO was asked to 1) determine the status of AHLTA, 2) determine DOD's plans for acquiring its new system, and 3) evaluate DOD's acquisition management of the initiative. To do this, GAO reviewed program plans, reports, and other documentation and interviewed DOD officials.

After obligating approximately $2 billion over the 13-year life of its initiative to acquire an electronic health record system, as of September 2010, DOD had delivered various capabilities for outpatient care and dental care documentation. DOD had scaled back other capabilities it had originally planned to deliver, such as replacement of legacy systems and inpatient care management. In addition, users continued to experience significant problems with the performance (speed, usability, and availability) of the portions of the system that have been deployed. DOD has initiated efforts to improve system performance and enhance functionality and plans to continue its efforts to stabilize the AHLTA system through 2015, as a "bridge" to the new electronic health record system it intends to acquire. According to DOD, the planned new electronic health record system--known as the EHR Way Ahead--is to be a comprehensive, real-time health record for service members and their families and beneficiaries. The system is expected to address performance problems, provide unaddressed capabilities such as comprehensive medical documentation, capture and share medical data electronically within DOD, and improve existing information sharing with the Department of Veterans Affairs. As of September 2010, the department had established a planning office, and this office had begun an analysis of alternatives for meeting the new system requirements. Completion of this analysis is currently scheduled for December 2010. Following its completion, DOD expects to select a technical solution for the system and release a delivery schedule. DOD's fiscal year 2011 budget request included $302 million for the EHR Way Ahead initiative. Weaknesses in key acquisition management and planning processes contributed to AHLTA having fewer capabilities than originally expected, experiencing persistent performance problems, and not fully meeting the needs of users.

1) A comprehensive project management plan was not established to guide the department's execution of the system acquisition. (2) A tailored systems engineering plan did not exist to guide the technical development of the system, an effort that was characterized by significant complexity. (3) Requirements were incomplete and did not sufficiently reflect user and operational needs. (4) An effective plan was not used to improve users' satisfaction with the system.

DOD has initiated efforts to bring its processes into alignment with industry best practices. However, it has not carried out a planned independent evaluation to ensure it has made these improvements. Until it ensures that these weaknesses are addressed, DOD risks undermining the success of further efforts to acquire electronic health record system capabilities. GAO is recommending that DOD take six actions to help ensure that it has disciplined and effective processes in place to manage the acquisition of further electronic health record system capabilities. In written comments on a draft of this report, DOD concurred with GAO's recommendations and described actions planned to address them.

(GAO-11-50)