DOD and VA Outpatient Pharmacy Data
Computable Data Are Exchanged for Some Shared Patients, but Additional Steps Could Facilitate Exchanging These Data for All Shared Patients Gao ID: GAO-07-554R April 30, 2007Since 1998, the Department of Defense (DOD) and the Department of Veterans Affairs (VA) have been working to electronically exchange patient health data, including outpatient pharmacy data, cross their electronic health information systems. Exchanging outpatient pharmacy data is important for DOD and VA because certain DOD and VA patients, known as shared patients, receive health care from both agencies. Clinicians' access to complete health information from both agencies' health information systems could assist clinicians in making more informed medical decisions and help prevent adverse medication reactions--which include detrimental or unintended reactions when multiple medications are taken together and allergic reactions to a medication. In March 2004, DOD and VA began collaborating on a long-term initiative to make their outpatient pharmacy data computable. Computable data refer to data that are in a format that a computer application can act on: for example, to provide automatic checks for adverse medication reactions or to plot graphs of changes in vital signs such as blood pressure. In reporting on this initiative in the past, GAO noted that the agencies have experienced delays in their efforts to begin exchanging computable outpatient pharmacy data. Concerned about DOD's and VA's progress in this effort, Congress asked GAO to examine the initiative that the agencies have under way to make their outpatient pharmacy data computable. In this report, GAO provides information on (1) DOD's and VA's expectations of what the exchange of computable outpatient pharmacy data will provide in safeguards against adverse medication reactions for shared patients, and (2) the status of DOD's and VA's initiative for attaining computable outpatient pharmacy data.
DOD and VA expect the exchange of computable outpatient pharmacy data to provide each agency with seamless access to shared patients' medication histories and more complete electronic checks for adverse medication reactions. Officials expect information on outpatient medications dispensed by either agency's health care system to be stored in each agency's repository in the standardized vocabulary each agency uses, following translation from a standardized set of terms, which will allow either agency's electronic health information system to include the other agency's data in its automatic checks. DOD and VA are exchanging computable outpatient pharmacy data for some shared patients, but have not completed steps important for exchanging these data for all shared patients. DOD and VA developed an electronic interface--Clinical Data Repository/Health Data Repository (CHDR)--that links DOD's and VA's health data repositories and allows for the exchange of computable data between them. DOD and VA have begun exchanging computable outpatient pharmacy data through CHDR for patients activated at seven locations as of March 2007. In addition, DOD officials indicated that all 117 DOD sites in the continental United States, Alaska, and Hawaii will be able to activate shared patients by the end of June 2007; VA indicated that all 128 VA sites will be able to activate shared patients by mid-September 2007. DOD and VA officials have identified two problems that prevent them from activating some shared patients. In some cases, patient information does not match exactly on all identifiers. In addition, VA patients who were discharged from active duty before 1997 may not have a unique identification number that DOD assigns to its beneficiaries, and without this number, these patients cannot be activated. VA must expand to all its 128 sites the capability to automatically check DOD data that are exchanged through CHDR. VA officials said this capability was in place at 10 sites as of March 2007 and expect it to be in place at all VA sites by the end of July 2007. While DOD and VA officials told us that guidelines for identifying shared patients would help sites determine which patients should be activated, the agencies have not established written guidelines, including criteria to define shared patients and procedures to identify shared patients, for all sites to use. DOD expects the guidelines to be completed by the end of June 2007. Until DOD and VA take additional steps to ensure all shared patients benefit from the exchange of computable pharmacy data, many shared patients will not receive the benefit of more complete automatic electronic checks for adverse medication reactions. To meet the timelines for resolving the three issues identified, it will be important for the agencies to make these efforts a priority, given previous delays in developing the capability to exchange computable data.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Team: Phone:GAO-07-554R, DOD and VA Outpatient Pharmacy Data: Computable Data Are Exchanged for Some Shared Patients, but Additional Steps Could Facilitate Exchanging These Data for All Shared Patients
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April 30, 2007:
The Honorable Ike Skelton:
Chairman:
The Honorable Duncan Hunter:
Ranking Member:
Committee on Armed Services:
House of Representatives:
The Honorable Vic Snyder:
Chairman:
The Honorable John M. McHugh:
Ranking Member:
Subcommittee on Military Personnel:
Committee on Armed Services:
House of Representatives:
Subject:DOD and VA Outpatient Pharmacy Data: Computable Data Are
Exchanged for Some Shared Patients, but Additional Steps Could
Facilitate Exchanging These Data for All Shared Patients:
Since 1998, the Department of Defense (DOD) and the Department of
Veterans Affairs (VA) have been working to electronically exchange
patient health data, including outpatient pharmacy data,[Footnote 1]
across their electronic health information systems. Exchanging
outpatient pharmacy data is important for DOD and VA because certain
DOD and VA patients, known as shared patients, receive health care from
both agencies. Clinicians' access to complete health information from
both agencies' health information systems could assist clinicians in
making more informed medical decisions and help prevent adverse
medication reactions--which include detrimental or unintended reactions
when multiple medications are taken together and allergic reactions to
a medication. In March 2004, DOD and VA began collaborating on a long-
term initiative to make their outpatient pharmacy data computable.
Computable data refer to data that are in a format that a computer
application can act on: for example, to provide automatic checks for
adverse medication reactions or to plot graphs of changes in vital
signs such as blood pressure.
In reporting on this initiative in the past, we have noted that the
agencies have experienced delays in their efforts to begin exchanging
computable outpatient pharmacy data.[Footnote 2] Concerned about DOD's
and VA's progress in this effort, you asked us to examine the
initiative that the agencies have under way to make their outpatient
pharmacy data computable. In this report, we provide information on:
² DOD's and VA's expectations of what the exchange of computable
outpatient pharmacy data will provide in safeguards against adverse
medication reactions for shared patients.
² The status of DOD's and VA's initiative for attaining computable
outpatient pharmacy data.
To address the objectives, we analyzed documents and interviewed
officials from DOD and VA about the agencies' efforts to exchange
computable outpatient pharmacy data for shared patients. We also viewed
a demonstration of DOD's and VA's exchange of computable outpatient
pharmacy data in El Paso, Texas, where DOD and VA first exchanged these
data for shared patients. We conducted our work from July 2006 through
April 2007 in accordance with generally accepted government auditing
standards.
On April 3, 2007, we provided a briefing to your offices on the results
of this work. The briefing slides, included as enclosure I, have been
updated to include more current information. This report summarizes the
information presented in the briefing and officially transmits our
recommendations to the Secretary of Defense and the Secretary of
Veterans Affairs.
Results in Brief:
DOD and VA expect the exchange of computable outpatient pharmacy data
to provide each agency with seamless access to shared patients'
medication histories and more complete electronic checks for adverse
medication reactions. Officials expect information on outpatient
medications dispensed by either agency's health care system to be
stored in each agency's repository in the standardized vocabulary each
agency uses, following translation from a standardized set of terms,
which will allow either agency's electronic health information system
to include the other agency's data in its automatic checks. According
to DOD and VA officials, having pharmacy data from both DOD and VA,
rather than data from a single agency, could reduce adverse medication
reactions by providing more complete checks for shared patients.
DOD and VA are exchanging computable outpatient pharmacy data for some
shared patients, but have not completed steps important for exchanging
these data for all shared patients. DOD and VA developed an electronic
interface--Clinical Data Repository/Health Data Repository (CHDR)--
that links DOD's and VA's health data repositories and allows for the
exchange of computable data between them. Before computable data can be
exchanged, patients who use both DOD's and VA's health care systems
must be identified as shared patients and then activated, which refers
to shared patients being matched on certain identifiers--first name,
last name, date of birth, Social Security Number--in both agencies'
health information systems and established as "active" shared patients.
DOD and VA have begun exchanging computable outpatient pharmacy data
through CHDR for patients activated at seven locations as of March
2007.[Footnote 3] In addition, DOD officials indicated that all
117[Footnote 4] DOD sites in the continental United States, Alaska, and
Hawaii will be able to activate shared patients by the end of June
2007; VA indicated that all 128 VA sites will be able to activate
shared patients by mid-September 2007. DOD and VA have been addressing
three issues that hinder their ability to exchange computable
outpatient pharmacy data for all shared patients.
² DOD and VA officials have identified two problems that prevent them
from activating some shared patients. In some cases, patient
information does not match exactly on all identifiers. In addition, VA
patients who were discharged from active duty before 1997 may not have
a unique identification number that DOD assigns to its beneficiaries,
and without this number, these patients cannot be activated. According
to DOD and VA, the agencies are working to resolve these problems. DOD
stated that in February 2007 it completed a software upgrade to help
resolve problems with matching patients' identifying information.
Similarly, VA officials told us that VA is developing a software
upgrade, but could not provide a date for when its upgrade would be
operational. In addition, DOD reported that it is working with a VA-
provided list of patients who are receiving care from VA and were
discharged from active duty before 1997. DOD reported that it will
create unique identification numbers for these patients and anticipates
this effort will be completed by the end of September 2007.
² VA must expand to all its 128 sites the capability to automatically
check DOD data that are exchanged through CHDR. VA officials said this
capability was in place at 10 sites as of March 2007 and expect it to
be in place at all VA sites by the end of July 2007.
² While DOD and VA officials told us that guidelines for identifying
shared patients would help sites determine which patients should be
activated, the agencies have not established written guidelines,
including criteria to define shared patients and procedures to identify
shared patients, for all sites to use. DOD expects the guidelines to be
completed by the end of June 2007.
Until DOD and VA take additional steps to ensure all shared patients
benefit from the exchange of computable pharmacy data, many shared
patients will not receive the benefit of more complete automatic
electronic checks for adverse medication reactions. To meet the
timelines for resolving the three issues identified, it will be
important for the agencies to make these efforts a priority, given
previous delays in developing the capability to exchange computable
data.
To help ensure that all shared patients benefit from the exchange of
computable outpatient pharmacy data, the Secretary of Defense and the
Secretary of Veterans Affairs should expedite certain ongoing efforts.
Specifically, we recommend that (1) the Secretary of Defense and the
Secretary of Veterans Affairs expedite efforts to develop a solution
for activating shared patients when patients' identifying information
does not match exactly, (2) the Secretary of Defense expedite efforts
to assign a unique DOD identification number to VA patients who were
discharged from active duty before 1997, (3) the Secretary of Veterans
Affairs expedite efforts to expand to all VA sites the capability to
automatically check DOD data that are exchanged through CHDR, and (4)
the Secretary of Defense and the Secretary of Veterans Affairs expedite
the development of written guidelines for all sites to use for defining
and identifying shared patients.
Agency Comments:
In commenting on a draft of this report, DOD and VA concurred with our
findings and recommendations. (DOD's and VA's comments are reprinted in
enclosures II and III, respectively.) DOD stated that it will expedite
efforts for the identified recommendations to be completed by the
specified time frames. VA stated that the two agencies are taking the
necessary steps to overcome issues that have hindered their ability to
exchange computable outpatient pharmacy data for all shared patients.
DOD and VA provided updated information on their efforts and DOD
provided technical comments. We incorporated updated information and
technical comments where appropriate.
We are sending copies of this report to the Secretary of Defense, the
Secretary of Veterans Affairs, and appropriate congressional
committees. We will also provide copies to others upon request. In
addition, the report is available at no charge on GAO's Web site at
http://www.gao.gov.
If you and your staff have any questions or need additional
information, please contact Laurie Ekstrand at (202) 512-7101 or
ekstrandl@gao.gov or Valerie Melvin at (202) 512-6304 or
melvinv@gao.gov. Contact points for our Offices of Congressional
Relations and Public Affairs may be found on the last page of this
report. Major contributors to this report were James Musselwhite,
Assistant Director; Barbara Oliver, Assistant Director; Janina Austin;
Jacqueline Bauer; Manuel Buentello; Christina C. Serna; and Eric Trout.
Signed by:
Laurie E. Ekstrand:
Director, Health Care:
Signed by:
Valerie C. Melvin:
Acting Director, Information Technology Human Capital and Management
Issues:
Enclosures - 3:
[End of section]
Enclosure I: Briefing:
DOD and VA Outpatient Pharmacy Data: Computable Data Are Exchanged for
Some Shared Patients, but Agencies Have Not Completed Steps Important
for Exchanging These Data for All Shared Patients:
Briefing to Congressional Staff:
Updated:
DOD and VA Outpatient Pharmacy Data: Computable Data Are Exchanged for
Some Shared Patients, but Agencies Have Not Completed Steps Important
for Exchanging These Data for All Shared Patients:
Congressional Requesters:
Chairman, Honorable Ike Skelton:
Ranking Member, Honorable Duncan Hunter:
House Committee on Armed Services:
Chairman, Honorable Vic Snyder:
Ranking Member, Honorable John M. McHugh:
Subcommittee on Military Personnel:
House Committee on Armed Services:
Overview:
Introduction:
Objectives:
Scope and Methodology:
Background:
Findings:
Introduction:
For decades, Congress has encouraged the Department of Defense (DOD)
and the Department of Veterans Affairs (VA) to increase their resource-
sharing activities to help clinicians-physicians and pharmacists-
deliver health care services more efficiently and increase the quality
of care provided to those who receive care from both DOD and VA.
Since 1998, DOD and VA have been working to electronically exchange
patient health data, including outpatient pharmacy data,[Footnote 5]
for active duty military personnel and veterans.
Exchanging outpatient pharmacy data is important for DOD and VA because
certain DOD and VA patients, known as shared patients, receive health
care from both agencies.
There are two ways shared patients may receive care from both DOD and
VA health care systems.
1. Through local agreements between DOD and VA, some patients may be
referred from one agency's facility to the other's for care that the
referring facility does not provide.
2. Based on DOD's and VA's respective criteria for health care
eligibility, some patients may be eligible for care under both systems
(for example, many military retirees are eligible for both DOD and VA
health care).
Clinicians' access to complete health information from both agencies'
health information systems could assist clinicians in making more
informed medical decisions.
Exchange of pharmacy data for shared patients could help prevent
adverse medication reactions-including detrimental or unintended
reactions when multiple medications are taken together and allergic
reactions to a medication.
The Bob Stump National Defense Authorization Act for Fiscal Year 2003
required DOD and VA to develop outpatient pharmacy data systems that
provide a real-time interface, data exchange, and checking of
prescription drug data using national standards by October 1,
2004.[Footnote 6]
In March 2004, DOD and VA began collaborating on a long-term initiative
to make their patient health data, including outpatient pharmacy data,
computable. Computable data refer to data that are in a format that a
computer application can act on: for example, to provide automatic
checks for adverse medication reactions or to plot graphs of changes in
vital signs such as blood pressure.
In reporting on this long-term initiative in the past, we have noted
that the agencies have experienced delays in their efforts to begin
exchanging computable outpatient pharmacy data.[Footnote 7] We reported
that DOD and VA originally planned to begin exchanging computable
outpatient pharmacy data by October 2005.
In 2004, DOD and VA also began a separate initiative to electronically
exchange read-only health data in near real-time for shared patients,
which would allow DOD and VA clinicians to view data from each other's
health information system. As of March 2007, all 128 VA sites and 22 of
138 DOD sites had the capability to electronically view data.[Footnote
8]
While DOD and VA officials said the capability to electronically view
patients' health data from both agencies' systems has improved the
quality of the health care they provide, agency officials expect
computable data to further enhance the quality of health care provided.
The capability of electronic health information systems to check and
provide alerts for adverse medication reactions supplements, but does
not replace, clinicians' standard practices of medical care, which
include asking patients about their medication and medication-allergy
histories and reviewing patients' medical files for their medication
histories.
Objectives:
1. To describe DOD's and VA's expectations of what the exchange of
computable outpatient pharmacy data will provide in safeguards against
adverse medication reactions for shared patients.
2. To provide the status of DOD's and VA's initiative for attaining
computable outpatient pharmacy data.
Scope and Methodology:
Analyzed documents and interviewed officials from DOD and VA about the
agencies' efforts to exchange computable outpatient pharmacy data for
shared patients.
Viewed demonstrations at medical facilities in the Washington, D.C.
area of the capabilities of DOD's and VA's electronic health
information systems. These demonstrations included how clinicians view
a patient's medication history and are alerted to adverse medication
reactions, but did not involve computable data.
Viewed a demonstration in El Paso, Texas of DOD's and VA's initiative
to exchange computable pharmacy data for shared patients at two co-
located sites-William Beaumont Army Medical Center and the El Paso VA
Health Care System-where DOD and VA first exchanged computable pharmacy
data for shared patients.
Conducted our work from July 2006 through April 2007 in accordance with
generally accepted government auditing standards.
Background:
DOD patients may receive health care and get medications from several
points of service.
DOD patients can receive health care from:
* DOD military treatment facilities (MTF) at 138 sites, which include
over 70 hospitals and 400 clinics:
* Private physicians (network and nonnetwork).[Footnote 9]
DOD patients can get medications from:
* MTF pharmacies:
* DOD's mail order pharmacy:
* Private pharmacies (network and nonnetwork).
VA patients may receive health care and get medications from the VA
health care system.
VA patients can receive health care from facilities at 128 VA sites,
which include 155 hospitals and 881 clinics.
VA patients can obtain medications from VA-facility pharmacies and VA's
seven mail order pharmacies.
In some cases, VA uses private physicians to provide care to patients
who are in need of a service that VA is unable to provide. If one of
these private physicians prescribes a medication, the medication is
filled at a VA pharmacy.
DOD and VA have each developed a repository-centralized electronic
storage-for health data, including data on medications dispensed and
patients' allergies to medications.
Patient health data from DOD's and VA's health care facilities and
pharmacies are aggregated in local databases maintained at DOD and VA
sites, respectively.
Patient data are transferred from DOD sites' local databases to DOD's
Clinical Data Repository (CDR)[Footnote 10] and from VA sites' local
databases to VA's Health Data Repository (HDR).
For example, the El Paso, Texas location has one DOD site and one VA
site. Patient health data from the DOD site, composed of one medical
center and two clinics, and the VA site, composed of three clinics, are
aggregated in each site's database and then transferred to the
corresponding agency's data repository.
DOD and VA clinicians can electronically view the medications dispensed
to patients at any facility in their respective health care systems
and, in certain cases, view medications dispensed to shared patients in
the other agency's system.
MTF physicians and MTF pharmacists can view information identifying
medications dispensed at all MTF pharmacies, DOD's mail order pharmacy,
private network pharmacies, and at private nonnetwork pharmacies if a
claim for reimbursement is submitted.
However, private physicians and private pharmacists (network and
nonnetwork) and DOD's mail order pharmacy are unable to electronically
view information identifying DOD patients' medications.
In addition, DOD physicians at the facilities associated with the 22
DOD sites capable of exchanging shared patient data can view
medications dispensed to shared patients at all VA facility pharmacies.
These data are not computable.
VA physicians and pharmacists at all VA facilities can electronically
view medications dispensed from all VA facility pharmacies, VA's mail
order pharmacies, and those IVITF pharmacies that exchange shared
patient data.
DOD and VA have developed automatic checks and alerts for their
respective health information systems.
DOD can perform automatic checks and provide alerts to MTF clinicians
if a new medication order will have an adverse medication reaction with
medications previously dispensed within DOD's health care
system[Footnote 11] - global checks-and medication allergies recorded
at all MTFs.
VA can perform automatic checks and provide alerts to VA clinicians if
a new medication order will have an adverse medication reaction with
medications ordered and dispensed and medication allergies recorded at
facilities associated with the same VA site-local checks.
As of March 2007, health care facilities at 10 VA sites could perform
global checks on medications ordered and dispensed and medication
allergies recorded at all VA facilities.
Exchanging computable data between agencies' health information systems
requires that the agencies adopt common standards for clinical
terminologies and for the transmission of information across systems.
In 2001, the Office of Management and Budget began the Consolidated
Health Informatics (CHI) initiative, which was a collaborative
agreement among federal agencies, including DOD and VA, to adopt a
common set of health information standards for the electronic exchange
of clinical health information.[Footnote 12]
As part of the CHI initiative, DOD and VA began to adopt standard
medication terminologies.
CHI did not identify common standards for medication allergies.
Findings:
DOD and VA Expect Computable Outpatient Pharmacy Data to Allow Seamless
Access to Shared Patients' Medication Histories and More Complete
Electronic Checks for Adverse Medication Reactions:
DOD and VA Are Exchanging Computable Outpatient Pharmacy Data for Some
Shared Patients, but Have Not Completed Steps Important for Exchanging
These Data for All Shared Patients:
DOD and VA Expect Computable Outpatient Pharmacy Data to Allow Seamless
Access to Shared Patients' Medication Histories and More Complete
Electronic Checks for Adverse Medication Reactions:
DOD and VA officials expect information on outpatient medications
dispensed to shared patients by either agency's health care system to
be stored in both agencies' health data repositories, which would
expand the data included in agencies' electronic checks for adverse
medication reactions.
Shared patients' health data, including medication and medication-
allergy data, are to be stored in each agency's repository in the
standardized vocabulary each agency uses, following translation from a
standardized set of terms, thus allowing either agency's electronic
health information system to process the other agency's data as if the
data had originated in its own system.
According to DOD and VA officials, this capability is expected to
enable automatic checks for adverse medication reactions and to enable
clinicians to receive automatic alerts for any adverse medication
reactions that have been identified, regardless of which agency's
facility dispensed the medication or recorded the medication-allergy
information.
Automated alerts are intended to inform physicians and pharmacists when
a newly prescribed medication is potentially adversely reactant to a
medication previously dispensed or whether a patient has an identified
allergy to the newly prescribed medication.
According to DOD and VA officials, using pharmacy data from both DOD
and VA, rather than data from a single agency, could reduce adverse
medication reactions by providing more complete checks for shared
patients.
DOD officials also expect computable outpatient pharmacy data to
increase the checking capabilities of private pharmacists in DOD's
network.
According to DOD officials, the medications that private pharmacists in
DOD's network dispense are expected to be checked for detrimental or
unintended reactions to medications previously dispensed within VA's
system; the pharmacist is to receive an alert if a potential adverse
reaction is found.
DOD and VA Are Exchanging Computable Outpatient Pharmacy Data for Some
Shared Patients, but Have Not Completed Steps Important for Exchanging
These Data for All Shared Patients:
DOD and VA have developed the capability to exchange computable
outpatient pharmacy data.[Footnote 13]
DOD and VA have developed an electronic interface-Clinical Data
Repository/Health Data Repository (CHDR)-that links DOD's CDR and VA's
HDR and allows for the exchange of computable data between the two data
repositories.
Before computable data can be exchanged, patients who use both DOD's
and VA's health care systems must be identified as shared patients and
then activated, which refers to shared patients being matched on
certain identifiers-first name, last name, date of birth, Social
Security Number-in both agencies' health information systems and
established as "active" shared patients.
DOD and VA are currently exchanging computable outpatient pharmacy data
through CHDR for patients activated at seven locations.[Footnote 14]
DOD and VA officials said that, as of March 2007, the agencies had
exchanged computable outpatient pharmacy data for about 4,000 patients
activated at the seven locations.
We viewed a successful demonstration of the exchange of computable
outpatient pharmacy data at one location in El Paso, Texas-the William
Beaumont Army Medical Center and the El Paso VA Health Care System.
In addition to El Paso, DOD and VA have begun exchanging computable
outpatient pharmacy data for patients activated at six other locations:
* Eisenhower Army Medical Center and Augusta VA Medical Center:
* Madigan Army Medical Center and VA Puget Sound Health Care System:
* Mike O'Callaghan Federal Hospital and VA Southern Nevada Health Care
System:
* Naval Health Clinic, Great Lakes and North Chicago VA Medical Center:
* Naval Hospital Pensacola and VA Gulf Coast Veterans Health Care
System:
* Naval Medical Center San Diego-Balboa and VA San Diego Health Care
System:
Locations of Sites Activating Shared Patients, March 2007:
[See PDF for image]
Sources: GAO analysis of DOD and VA information, Map Resources (map).
[End of figure]
DOD and VA officials anticipate that all sites in the continental
United States, Alaska, and Hawaii will activate shared patients.
DOD officials expect that all 117[Footnote 15] DOD sites in the
continental United States, Alaska, and Hawaii will be able to activate
shared patients by the end of June 2007.
VA officials expect that all 128[Footnote 16] VA sites will be able to
activate shared patients by mid-September 2007.
Although all sites are not currently activating shared patients,
officials indicated that all DOD and VA sites can exchange computable
pharmacy data for patients previously activated at other sites.
DOD and VA have been addressing issues that the agencies acknowledge
have hindered their ability to exchange all computable outpatient
pharmacy data for activated shared patients.
Because a national standard does not exist for medication-allergy data,
DOD and VA have agreed on and adopted a standard for exchanging these
data.
Adopted standard medication terminologies do not include terminologies
for all medications.
Standard medication terminologies must be continuously updated as new
medications become available.
DOD and VA have developed a team to review data that cannot be
exchanged[Footnote 17] and to work toward improving the percentage of
data that can be exchanged.
DOD and VA have been exchanging computable outpatient pharmacy data.
Percentage of Data Exchanged on Medications Dispensed and on Medication-
allergies for Shared Patients Activated as of December 2006:
Data: VA to DOD;
Medications dispensed: 90;
Medication allergies: 78.
Data: DOD to VA;
Medications dispensed: 93;
Medication allergies: 65.
Source: DOD and VA officials.
Note: According to DOD and VA officials, approximately 3,500 shared
patients were activated as of December 2006. Data may not exchange for
several reasons, including lack of standard terminologies and
formatting errors.
[End of table]
DOD and VA have been addressing issues that the agencies acknowledged
have hindered their ability to activate all shared patients.
According to DOD and VA officials, in some cases, patient information
does not match exactly on all identifiers.
For example, patients may present themselves using a nickname for one
system and a full name for the other system. In these instances, DOD
and VA cannot activate these patients.
DOD assigns a unique number to DOD beneficiaries, which is needed to
activate shared patients. However, VA patients who were discharged from
active duty before 1997 may not have this unique number.
Without this unique number, patients cannot be recognized by DOD's PDTS
and therefore cannot be activated as shared patients.
To help resolve problems with matching patients' identifying
information, DOD reported that in February 2007 it completed a software
upgrade that officials expect will reduce DOD's error rate for
activating shared patients to less than 5 percent. Similarly, VA
officials told us that VA is developing a software upgrade, but could
not provide a date for when the upgrade would be operational.
For VA patients lacking a unique DOD number, DOD reported that it is
working with a VA-provided list of patients who are receiving care from
VA and were discharged from active duty before 1997. DOD reported that
it will create unique identification numbers for these patients and
anticipates this effort will be completed by the end of September 2007.
VA must expand its current capability to conduct global automatic
checks to all VA sites before all sites can benefit from automatic
checks allowed by computable outpatient pharmacy data.[Footnote 18]
The capability for VA sites to conduct global automatic checks of
medications ordered and dispensed and medication allergies recorded at
all VA facilities is needed for all VA sites to conduct more
comprehensive checks across all VA sites and to automatically check DOD
data that are exchanged through CHDR.
The capability allows VA's health information system to process data
originating from DOD as though the data originated from another VA
site.
VA officials told us that until the capability for global automatic
checks is in place at a VA site, the VA site will likely not activate
shared patients.
VA officials said that as of March 2007 this capability is in place at
10 sites and expect it to be in place at all VA sites by the end of
July 2007.
According to DOD and VA officials, the agencies have not established
written guidelines for all sites to use for identifying shared
patients.
DOD and VA officials told us they instructed the seven locations that
are currently activating patients to identify shared patients as those
who have previously received care from both agencies.
DOD and VA officials told us that guidelines for all sites to use for
identifying shared patients, including criteria defining a shared
patient and procedures for identifying shared patients, would help
sites determine which patients should be activated. However, the
agencies have not established written guidelines for all sites.
Agency officials stated that the development of guidelines for all
sites to use are under way and DOD expects the guidelines to be
completed by the end of June 2007. Officials said that customization of
the guidelines may be necessary because of site-specific situations,
such as local agreements.
[End of section]
Enclosure II: Comments from the Department of Defense:
The Assistant Secretary Of Defense:
1200 Defense Pentagon:
Washington, DC 203011200:
Health Affairs:
Apr 1 3 2007:
Ms. Laurie E. Ekstrand:
Director, Health Care:
U.S. Government Accountability Office:
441 G Street, N.W.
Washington, DC 20548:
Dear Ms. Ekstrand:
This is the Department of Defense (DoD) response to the U.S. Government
Accountability Office (GAO) draft report, "DoD and Veterans Affairs
Outpatient Pharmacy Data: Computable Data Are Exchanged for Some Shared
Patients, but Additional Steps Could Facilitate Exchanging These Data
for All Shared Patients," dated April 4, 2007 (GAO Code 290552/GAO-07-
554-R).
The DoD acknowledges receipt of the GAO draft report and concurs with
the overall findings and recommendations. Specifically, DoD will
expedite efforts for the identified recommendations to be completed by
the specified timeframes.
Enclosed are specific responses and two technical comments to GAO's
draft report recommendations. Please feel free to direct any questions
on this matter to our Project Officer, Ms. Pamela Schmidt, at (703) 681-
8830, or Mr. Gunther Zimmerman (GAO Liaison), at (703) 681-3492.
Sincerely,
Signed by:
William Winkenwerder, Jr., MD:
Enclosures:
As stated:
GAO Draft Report - Dated April 4, 2007 GAO Code 290552/GAO-07-554R:
"DoD and VA Outpatient Pharmacy Data: Computable Data Are Exchanged for
Some Shared Patients, but Additional Steps Could Facilitate Exchanging
These Data for All Shared Patients"
Department Of Defense Comments To The Recommendations:
Recommendation 1: The GAO recommends that the Secretary of Defense and
the Secretary of Veterans Affairs expedite efforts to develop a
solution for activating shared patients when patients' identifying
information does not match exactly. (pgs. 3-4/GAO Draft Report):
DoD Response: Concur. The DoD and VA are working collaboratively to
resolve this issue. A DoD system upgrade completed Feb 2007 is expected
to reduce the error rate for activating shared patients to less than 5
percent.
Recommendation 2: The GAO recommends that the Secretary of Defense and
the Secretary of Veterans Affairs expedite efforts to assign a unique
DOD identification number to VA patients who were discharged from
active duty before 1997. (pg. 4/GAO Draft Report):
DoD Response: Concur. In the Common Population project, the VA is
working with Defense Manpower Data Center (DMDC) to add the VA patients
who were discharged from active duty prior to 1997 and are receiving
health care in VA. Once the listing of VA patients is received by DMDC,
it will take approximately 30 days to create the unique identification
numbers. We anticipate this work will be completed in 4Q FY 2007.
Recommendation 4: The GAO recommends that the Secretary of Defense and
the Secretary of Veterans Affairs expedite the development of written
guidelines for all sites to use for defining and identifying shared
patients. (pg. 4/ GAO Draft Report):
DoD Response: Concur. The DoD currently has guidelines under
development and in coordination with the Services. We expect to
complete this task in 3Q FY 2007.
[End of section]
Enclosure III: Comments from the Department of Veterans Affairs:
The Secretary Of Veterans Affairs:
Washington:
April 18, 2007:
Ms. Laurie Ekstrand:
Director, Health Care:
and:
Ms. Valerie C. Melvin:
Acting Director, Information Technology:
Human Capital and Management Issues:
U. S. Government Accountability Office:
441 G Street, NW:
Washington, DC 20548:
Dear Ms. Ekstrand and Ms Melvin:
The Department of Veterans Affairs (VA) has reviewed your draft report,
DOD and VA Outpatient Pharmacy Data: Computable Data Are Exchanged for
Some Shared Patients, but Additional Steps Could Facilitate Exchanging
These Data for All Shared Patients (GAO-07-554R) and agrees with your
conclusions and concurs in your recommendations directed to VA.
While VA and DoD have encountered certain obstacles that have hindered
our ability to exchange computable outpatient pharmacy data for all
active dual consumers, both agencies are taking the necessary steps to
overcome these issues. VA and DoD are well on the path to accomplishing
a critical milestone in our ability to electronically exchange multiple
types of patient health data between our health information systems. By
September 14, 2007, all 128 VA sites will be able to activate shared
patients. Considering that VA and DoD, in many respects, are at the
forefront of facilitating electronic health data exchange across
disparate information systems, this will be a notable accomplishment in
our continuing efforts to provide high quality care for both active
duty service members and veterans.
The enclosure details VA steps to implement your recommendations
directed to the Department of Veterans Affairs. VA appreciates the
opportunity to comment on your draft report.
Sincerely yours,
Signed by:
R. James Nicholson:
Enclosure:
Department of Veterans Affairs (VA) comments to Government
Accountability Office (GAO) draft report DOD and VA Outpatient Pharmacy
Data: Computable Data Are Exchanged for Some Shared Patients, but
Additional Steps Could Facilitate Exchanging These Data for All Shared
Patients (GAO-07-554R):
To help ensure that all shared patients benefit from the exchange of
computable outpatient pharmacy data, the Secretary of Defense and the
Secretary of Veterans Affairs should expedite certain ongoing efforts.
Specifically, GAO recommends that:
* the Secretary of Defense and the Secretary of Veterans Affairs
expedite efforts to develop a solution for activating shared patients
when patients' identifying information does not match exactly.
Concur - The Veterans Health Administration (VHA) acknowledges the
necessity to improve the rate of matching between DoD and VA patients
for whom computable pharmacy data are shared when their identifying
information does not exactly match. VHA is working with DoD to provide
a VA file that will permit DoD to match patients and issue Defense
Enrollment Eligibility Reporting System (DEERS) ID numbers for those
veterans who do not have already have one and are reasonably expected
to receive care from both systems (i.e., registered in the VA Master
Patient Index). This work includes activities to ensure that the
proposed solution meets all applicable security and privacy
requirements.
* the Secretary of Veterans Affairs expedite efforts to expand to all
VA sites the capability to automatically check DOD data that are
exchanged through CHDR.
Concur - VHA acknowledges the necessity to expand Clinical Data
Repository/Health Data Repository (CHDR) capability for automatic drug
and allergy checks to all 128 VA (Veterans Health Information Systems
and Technology Architecture [VistA]) sites. In order to expand
capability to all VA sites, VHA is currently working to complete
testing on the Remote Data Interoperability (RDI) application and to
approve RDI for national release. RDI is the application that supports
the ability of VA to conduct the checks against data in the Health Data
Repository (remote VA data and DoD data).
* the Secretary of Defense and the Secretary of Veterans Affairs
expedite the development of written guidelines for all sites to use for
defining and identifying shared patients.
Concur - VA and Doll) have completed the written guidelines and are
currently planning to jointly present them to the Health Executive
Council (HEC) Information Management/Information Technology (IMIT)
workgroup on April 26, 2007, for approval.
[End of section]
(290552):
FOOTNOTES
[1] Patient health data also include demographic, radiology,
laboratory, and allergy data. Outpatient pharmacy data refer to
information on medications dispensed and medication allergies.
[2] GAO, Information Technology: VA and DOD Face Challenges in
Completing Key Efforts, GAO-06-905T (Washington, D.C.: June 22, 2006).
[3] Each location includes one DOD site and one VA site at the same
location or in close proximity. A site represents one or more
facilities--medical centers, hospitals, or outpatient clinics--that
store their electronic health data in a single database.
[4] According to DOD officials, there are a total of 138 sites, 21 of
which are located outside the United States and will likely not
activate patients.
[5] Patient health data also include demographic, radiology,
laboratory, and allergy data. Outpatient pharmacy data refer to
information on medications dispensed and medication allergies.
[6] Pub. L. No. 107-314, § 724, 116 Stat. 2458, 2598 (2002). In
September 2004, the agencies completed testing of a prototype that
allowed their systems to demonstrate these capabilities.
[7] GAO, Information Technology. VA and DOD Face Challenges in
Completing Key Efforts, GAO-06-905T (Washington, D.C.: June 22, 2006).
[8] A site represents one or more facilities-medical centers,
hospitals, or outpatient clinics-that store their electronic health
data in a single database.
[9] Network refers to TRICARE's network-a regionally structured program
that uses civilian contractors to maintain provider and pharmacy
networks to complement health care services provided at MTFs.
[10] Information on medications dispensed is aggregated and transferred
to CDR by DOD's Pharmacy Data Transaction Service (PDTS). DOD also uses
PDTS for pharmacy billing and for verifying whether patients are
eligible for DOD pharmacy benefits.
[11] Medications previously dispensed within DOD's health care system
include medications dispensed at MTFs, DOD's mail order pharmacy,
private network pharmacies, and at private nonnetwork pharmacies if a
claim for reimbursement is submitted.
[12] According to DOD and VA officials, on September 30, 2006, the CHI
initiative was dissolved and will be integrated with the Health
Information Technology Standards Panel, a public-private collaborative
effort.
[13] DOD and VA envision exchanging other computable patient health
data through CHDR. Agency officials indicated that they also have
efforts underway to develop the capability to exchange computable
clinical laboratory data.
[14] Each location represents one DOD site and one VA site in the same
location or in close proximity.
[15] According to DOD officials, 21 of the agency's 138 sites are
outside the United States and will likely not activate patients.
[16] According to VA officials, all of the agency's 128 sites are
within the United States.
[17] Data may not be exchanged for reasons other than lack of
standards, including formatting errors.
[18] All DOD sites currently have the capability to conduct global
automatic checks.
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