October 21, 2021

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Electronic Health Records: DOD Has Made Progress in Implementing a New System, but Challenges Persist

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<div>What GAO Found The Department of Defense (DOD) made progress toward implementing its new electronic health record system, MHS GENESIS. DOD deployed the new system to sites in six of 24 planned deployment phases (i.e., waves), which included about 41,600 users (see figure). DOD also improved system performance and addressed issues experienced at the initial sites. Even with this progress, incidents identified during testing—such as system defects—remain unresolved. DOD has not developed plans to conduct additional testing at future sites to ensure the remaining incidents are fully resolved. As a result, unaddressed incidents could lead to challenges at future sites. Actual and Planned MHS GENESIS Deployments, 2017-2023, as of June 2021 Additionally, implementation of MHS GENESIS faced training and communication challenges. Test results and selected system users indicated that training for MHS GENESIS and the dissemination of system change information were ineffective. For example, the users stated that training was not consistent with the “live” system. Further, users reported that there were too many system changes to keep up with and that they were not adequately informed as changes were implemented. As a result, users were unaware of important changes to their roles or business processes, or to system revisions and improvements. These challenges could hinder users' ability to effectively use the system, impede their knowledge of new workflows, and limit the utility of system improvements. Regarding key program risks, DOD identified and was tracking risks and their associated mitigation plans. Why GAO Did This Study DOD relies on multiple legacy electronic health record systems to create, maintain, and manage patient health information. DOD has determined that these systems, implemented over the past 3 decades, require modernization and replacement. The department has sought to replace these legacy systems with a comprehensive, real-time electronic health record. The conference report accompanying the Department of Defense and Labor, Health and Human Services, and Education Appropriations Act, 2019 and Continuing Appropriations Act, 2019 included a provision for GAO to review DOD's electronic health record deployment. GAO's objectives were to (1) determine what progress DOD has made toward implementing a new electronic health record system, and (2) identify the challenges and key risks to MHS GENESIS implementation and what steps DOD is taking to address them. To do so, GAO analyzed test reports, briefing materials, and incident report tracking documents. GAO also held discussion groups with 356 users at selected sites and interviewed relevant officials.</div>

What GAO Found

The Department of Defense (DOD) made progress toward implementing its new electronic health record system, MHS GENESIS. DOD deployed the new system to sites in six of 24 planned deployment phases (i.e., waves), which included about 41,600 users (see figure). DOD also improved system performance and addressed issues experienced at the initial sites. Even with this progress, incidents identified during testing—such as system defects—remain unresolved. DOD has not developed plans to conduct additional testing at future sites to ensure the remaining incidents are fully resolved. As a result, unaddressed incidents could lead to challenges at future sites.

Actual and Planned MHS GENESIS Deployments, 2017-2023, as of June 2021

Additionally, implementation of MHS GENESIS faced training and communication challenges. Test results and selected system users indicated that training for MHS GENESIS and the dissemination of system change information were ineffective. For example, the users stated that training was not consistent with the “live” system. Further, users reported that there were too many system changes to keep up with and that they were not adequately informed as changes were implemented. As a result, users were unaware of important changes to their roles or business processes, or to system revisions and improvements. These challenges could hinder users’ ability to effectively use the system, impede their knowledge of new workflows, and limit the utility of system improvements. Regarding key program risks, DOD identified and was tracking risks and their associated mitigation plans.

Why GAO Did This Study

DOD relies on multiple legacy electronic health record systems to create, maintain, and manage patient health information. DOD has determined that these systems, implemented over the past 3 decades, require modernization and replacement. The department has sought to replace these legacy systems with a comprehensive, real-time electronic health record.

The conference report accompanying the Department of Defense and Labor, Health and Human Services, and Education Appropriations Act, 2019 and Continuing Appropriations Act, 2019 included a provision for GAO to review DOD’s electronic health record deployment. GAO’s objectives were to (1) determine what progress DOD has made toward implementing a new electronic health record system, and (2) identify the challenges and key risks to MHS GENESIS implementation and what steps DOD is taking to address them.

To do so, GAO analyzed test reports, briefing materials, and incident report tracking documents. GAO also held discussion groups with 356 users at selected sites and interviewed relevant officials.

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  • Weapon Systems Annual Assessment: Updated Program Oversight Approach Needed
    In U.S GAO News
    GAO's 19th annual assessment of the Department of Defense's (DOD) weapon programs comes at a time of significant internal changes to the department's acquisition process. Specifically, DOD began implementing its new acquisition framework intended to, among other things, deliver solutions to the end user in a timely manner. However, GAO found that many programs have planned acquisition approaches that, unless properly managed and overseen, could result in cost and schedule challenges similar to those GAO has reported on for nearly the past 2 decades. DOD's new acquisition framework allows program managers to use one or more of six acquisition pathways—including the major capability acquisition and middle-tier acquisition (MTA) pathways used by the programs GAO reviewed. Each pathway is governed by separate policies for milestones, cost and schedule goals, and reporting. Program managers can tailor, combine, and transition between pathways based on program goals and risks associated with the weapon system being acquired (see figure). Notional Use of Multiple Efforts and Multiple Pathways DOD's framework also introduces new considerations to program oversight. In particular, DOD has yet to develop an overarching data collection and reporting strategy for programs transitioning between acquisition pathways or conducting multiple efforts using the same pathway to deliver the intended capability. The lack of a strategy not only limits DOD's visibility into these programs but also hinders the quality of its congressional reporting and makes the full cost and schedule of the eventual weapon system more difficult to ascertain. DOD Plans to Invest Over $1.79 Trillion in Its Costliest Weapon Programs, but Not All Costs Are Reported DOD's reported costs primarily reflect major defense acquisition program (MDAP) investments (see table). However, DOD is increasingly using the MTA pathway to acquire weapon programs . The totals do not include all expected costs because, among other things, MTA estimates do not reflect any potential investments after the current MTA effort, and cost figures do not include programs that have yet to formally select a pathway or are classified or sensitive. Department of Defense Total Investments in Selected Weapon Programs GAO Reviewed (fiscal year 2021 dollars in billions)   Procurement reductions in DOD's costliest program—the F-35—drove an MDAP portfolio cost decrease since GAO's last annual report (see figure). Excluding this program, quantity changes and other factors such as schedule delays contributed to one-year portfolio cost growth. Sixteen MDAPs also showed schedule delays since GAO's 2020 report. Such delays are due, in part, to delivery or test delays and poor system performance. Major Defense Acquisition Program One-Year Cost Change Including and Excluding the F-35 Program (fiscal year 2021 dollars in billions) F-35 reported an overall procurement cost decrease of $23.9 billion in fiscal year 2020, primarily due to lower prime and subcontractor labor rates. As GAO found last year, DOD continues to expand its portfolio of the costliest MTA programs, expecting to spend $30.5 billion on current efforts. Due to inconsistent cost reporting by MTA programs, GAO could not assess cost trends across the MTA portfolio. However, GAO observed examples of cost changes on certain MTA programs compared with last year. Weapon Programs Do Not Consistently Plan to Attain Knowledge That Could Limit Cost Growth and Deliver Weapon Systems Faster Most MDAPs continue to forgo opportunities to improve cost and schedule outcomes by not adhering to leading practices for weapon system acquisitions. Some MTA programs also reported planning to acquire only limited product knowledge during program execution, leading to added risks to planned follow-on efforts. Further, while both MDAPs and MTA programs increasingly reported using modern software approaches and cybersecurity measures, they inconsistently implemented leading practices, such as frequently delivering software to users and conducting certain types of cybersecurity assessments during development. Why GAO Did This Study Title 10, section 2229b of the U.S. Code contains a provision for GAO to review DOD's weapon programs. This report assesses the following aspects of DOD's costliest weapon programs: their characteristics and performance, planned or actual implementation of knowledge-based acquisition practices, and implementation of selected software and cybersecurity practices. The report also assesses oversight implications of DOD's changes to its foundational acquisition guidance. GAO identified programs for review based on cost and acquisition status; reviewed relevant legislation, policy, guidance, and DOD reports; collected program office data; and interviewed DOD officials .
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