VA and Defense Health Care
Increased Risk of Medication Errors for Shared Patients Gao ID: GAO-02-1017 September 27, 2002Medication errors and adverse drug reactions are a significant concern for the Department of Veterans Affairs (VA) and the Department of Defense (DOD) because their large beneficiary populations receive many prescriptions. Each agency has taken steps to reduce the risk of medication errors, such as making patients' medical records more accessible to providers and performing checks for drug interactions. Although each agency has designed safeguards to protect its own patients, some VA and DOD patients receive medication from both agencies. Shared patients face a higher risk of medication error. Joint (DOD and VA) venture sites with inpatient facilities provide services to shared inpatients in the same manner as they do for their own beneficiaries; that is, medications are ordered using the facility's guidelines and filled through the inpatient pharmacy at that facility. Gaps in safeguards result primarily from VA's and DOD's separate, uncoordinated information and formulary systems. Joint venture sites have tried to address some of these safety gaps. For instance, all sites have made patient information more accessible by providing additional, although incomplete, access to the other agency's patient information system.
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-02-1017, VA and Defense Health Care: Increased Risk of Medication Errors for Shared Patients
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United States General Accounting Office:
GAO:
Report to Chairman, Subcommittee on Defense, Committee on
Appropriations, U.S. Senate:
September 2002:
VA And Defense Health Care:
Increased Risk of Medication Errors for Shared Patients:
GAO-02-1017:
Contents:
Letter:
Results in Brief:
Background:
Shared Patients Obtain Inpatient Drugs from the Treating Agency but
Generally Return to Home Agency for Outpatient Drugs:
Shared Patients Experience Gaps in Medication Safety Measures:
Safety Gaps Remain Despite Efforts to Address Them:
Conclusions:
Recommendations For Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Comments from the Department of Veterans Affairs:
Appendix II: Comments from the Department of Defense:
Appendix III: GAO Contacts and Staff Acknowledgments:
Table:
Table 1: Description of Joint Venture Sites and Services as of August
2002:
Figures:
Figure 1: Safeguards in Process Typically Used by VA and DOD to Provide
Medications to Their Own Beneficiaries:
Figure 2: Gaps in Medication Safeguards for Shared Patients:
Abbreviations:
ADE: adverse drug event:
ASHP: American Society of Health-System Pharmacists:
DOD: Department of Defense:
CHCS: Composite Health Care System:
CPOE: computerized provider order entry:
CPRS: Computerized Patient Record System:
FHIE: Federal Health Information Exchange:
GCPR: Government Computer-Based Patient Record:
IOM: Institute of Medicine:
IHS: Indian Health Service:
ISMP: Institute for Safe Medication Practices:
JCAHO: Joint Commission on Accreditation of Healthcare Organizations:
MTF: military treatment facility:
PDTS: Pharmacy Data Transaction Service:
P&T: pharmacy and therapeutics:
VA: Department of Veterans Affairs:
[End of section]
United States General Accounting Office:
Washington, DC 20548:
September 27, 2002:
The Honorable Daniel K. Inouye:
Chairman:
Subcommittee on Defense:
Committee on Appropriations:
United States Senate:
Dear Mr. Chairman:
Adverse drug events (ADE), which include adverse drug reactions and
preventable medication errors, have gained national attention in recent
years. The risk of medication errors is an important issue for the
Department of Veterans Affairs (VA) and the Department of Defense
(DOD), in part because their large beneficiary populations receive many
prescriptions”in fiscal year 2000, 86 million and 66 million,
respectively. Each agency has recognized the significance of medication
errors and has instituted practices to reduce them, such as making
patients‘ medical records more accessible to providers and performing
checks for drug interactions. Although each agency designed safeguards
to protect its own patients, certain VA and DOD patients receive
medications from both agencies”either because they are eligible for
care under both systems or because they are referred from one agency to
the other under VA-DOD health resources sharing agreements. Preventing
medication errors for these shared patients presents an additional
challenge.
VA and DOD estimate that about 800,000 beneficiaries are dually eligible
for care from VA and DOD and an unknown number of additional
beneficiaries receive care through sharing agreements.[Footnote 1]
Concerned about the effectiveness of medication safeguards for shared
patients, you asked us to determine (1) from which agency shared
patients obtain medications, (2) whether gaps exist in medication
safeguards for shared patients, and (3) if gaps exist, how they are
being addressed.
To conduct our work, we reviewed VA‘s and DOD‘s processes for providing
outpatient and inpatient medications to shared patients. To focus our
review on locations with large numbers of shared patients, we examined
VA and DOD‘s seven joint ventures, which have had experience working
together under sharing agreements. At your request, we conducted an on-
site review of pharmacy operations at the joint venture in Hawaii,
where there is an agreement between Tripler Army Medical Center and the
VA Medical and Regional Office Center. At this site, we observed how
medications are provided to shared patients and evaluated these
processes for gaps in medication safeguards. We also examined
medication error reports and interviewed VA and DOD providers,
pharmacists, patient safety personnel, and information systems
personnel. We spoke by telephone with personnel in similar positions at
the six other joint venture sites to identify procedures used to
provide medications to shared patients and evaluated these procedures
for medication safety gaps. We spoke with personnel at all joint
venture sites about their medication safety programs, but we were not
able to identify errors specific to shared patients because neither VA
nor DOD tracks information in this way.
We also spoke with VA and DOD headquarters personnel knowledgeable
about pharmacy, patient safety, formulary, and information technology
issues.[Footnote 2] In addition, we reviewed the literature on
medication errors and consulted experts on patient safety and
medication errors from the Joint Commission on Accreditation of
Healthcare Organizations (JCAHO); the Institute for Safe Medication
Practices (ISMP); and the Leapfrog Group for Patient Safety, a
coalition of more than 100 public and private organizations that
provide health care benefits. We conducted our work from February 2002
through September 2002 in accordance with generally accepted government
auditing standards.
Results in Brief:
Joint venture sites with inpatient facilities provide pharmacy services
to shared inpatients in the same manner as they do for their own
beneficiaries, that is, medications are ordered using the facility‘s
guidelines and filled through the inpatient pharmacy at that facility.
Although the process for providing medications to shared outpatients
differs across sites, generally each agency expects its beneficiaries
to use its own, separate pharmacy for outpatient prescriptions, even
when prescriptions are ordered by providers from the other agency. At
one joint venture, a single DOD pharmacy provides medications for both
VA and DOD outpatients. However, VA patients obtain only initial, short-
term prescriptions at this DOD pharmacy; longer-term prescriptions and
refills are obtained by mail from VA.
Shared patients face an increased risk of medication errors. Gaps in
safeguards result primarily from VA‘s and DOD‘s separate, uncoordinated
information and formulary systems. Providers and pharmacists at joint
venture sites generally do not have access to shared patients‘ complete
health information to aid in making medication decisions because
information in one agency‘s electronic health record system is generally
not accessible by the other agency. Also, providers of one agency
generally cannot use computerized provider order entry (CPOE) to order
drugs that are to be dispensed in the other agency‘s pharmacy. As a
result, the potential for error is introduced when prescriptions are
handwritten or reentered into the other agency‘s pharmacy system.
Moreover, automatic checks for drug allergies and interactions are not
complete for shared patients because medications dispensed by the other
agency will not be included in the check. VA‘s and DOD‘s separate
formulary systems also complicate providing medications to shared
patients because providers either prescribe from the other agency‘s
formulary, which may contain unfamiliar drugs, or prescribe a limited
supply of a drug, which may later be switched to comply with the
formulary of the patient‘s home agency.[Footnote 3] Such switching puts
the patient at greater risk for an adverse drug reaction.
Joint venture sites have taken steps to address some of these safety
gaps. For instance, all sites have made patient information more
accessible by providing additional, although incomplete, access to the
other agency‘s patient information system. Some sites have produced
computer-printed, rather than handwritten, prescriptions or developed
practices to collect information on medications that patients are using
from other sources, for instance, those obtained from the other agency.
In addition, some have addressed the problems created by separate
formulary systems by having both agencies represented on the pharmacy
and therapeutics (P&T) committee, the group that makes decisions about
drugs included on the formulary, or by stocking nonformulary drugs used
by the other agency. However, none of these practices fully addresses
the safety gaps. In addition, the use of such practices varies by site.
We are recommending that VA and DOD improve procedures, especially
relating to sharing of electronic information, for patients using both
systems so that they are not at greater risk of medication errors than
if they received their care from only one system. In its comments to
our draft report, VA concurred with all our recommendations. DOD
concurred with our recommendations to develop the capability for VA and
DOD providers to access patient information in both agencies‘ patient
information systems and to develop comprehensive drug interaction
checks that include both VA- and DOD-provided drugs. DOD also agreed to
require providers to use CPOE for shared patients where it is
available. It disagreed with modifying the current systems as a way of
extending this capability because both agencies have longer-term plans
to upgrade or replace their pharmacy information system modules.
However, because of the time it will take to upgrade or replace the
system modules, shared patients continue to be at risk for medication
errors. DOD also said that it did not concur with establishing a joint
P&T committee at each joint venture site. We recommended the
establishment of either a joint P&T committee or a similar working
group, and DOD indicated support for such working groups.
Background:
To encourage the sharing of federal health care resources, the Veterans
Administration and Department of Defense Health Resources Sharing and
Emergency Operations Act authorizes VA medical centers and DOD
military treatment facilities (MTF) to enter into sharing agreements to
buy, sell, and barter medical and support services.[Footnote 4] Local
VA and DOD officials have identified benefits that have resulted from
such sharing, including increased revenue, enhanced staff proficiency,
fuller utilization of staff and equipment, improved beneficiary access,
and reduced cost of services.[Footnote 5]
Seven of these sharing agreements are joint venture agreements, which
involve the sharing of physical space as well as health care services.
These joint ventures range from a single, jointly staffed MTF serving
both VA and DOD patients”as is the case with Mike O‘Callaghan Federal
Hospital at Nellis Air Force Base in Nevada”to more modest sharing in
Key West, Florida, where VA and DOD share a building that houses their
separate outpatient clinics. In addition to physical space, agreements
at these sites usually provide for one agency to refer patients to the
other for inpatient and/or outpatient care. As table 1 shows, DOD is
most often the host agency, that is, the agency providing the majority
of services.
Table 1: Description of Joint Venture Sites and Services as of August
2002:
Joint venture: Alaska: Elmendorf Hospital, Elmendorf Air Force Base;
Alaska VA Healthcare System and Regional Office;
Host agency: DOD;
General description of health care services shared: Air Force hospital
serves DOD and VA inpatients. Air Force also provides certain outpatient
specialty care for VA patients.
Joint venture: California: David Grant Medical Center, Travis Air Force
Base; VA Northern California Health Care System;
Host agency: DOD;
General description of health care services shared: Air Force hospital
at Travis Air Force Base serves DOD and VA inpatients. Air Force also
provides certain outpatient specialty care for VA patients. VA hospital
at Sacramento provides certain specialty outpatient care to DOD
patients.
Joint venture: Florida[A]: Key West Naval Branch Clinic; VA Community
Based Clinic;
Host agency: DOD;
General description of health care services shared: DOD provides
outpatient pharmacy medications to both DOD and VA patients.[B]
Joint venture: Hawaii: Tripler Army Medical Center; Honolulu VA Medical
and Regional Office Center;
Host agency: DOD;
General description of health care services shared: Army hospital
serves DOD and VA inpatients. Army also provides certain outpatient
specialty care for VA patients.
Joint venture: Nevada: Mike O‘Callaghan Federal Hospital, Nellis Air
Force Base; VA Southern Nevada Healthcare System;
Host agency: DOD;
General description of health care services shared: Jointly staffed Air
Force hospital serves DOD and VA inpatients. Hospital also provides
certain outpatient specialty care for both VA and DOD patients.
Joint venture: New Mexico: United States Air Force Clinic, Kirtland Air
Force Base; New Mexico VA Health Care System;
Host agency: VA;
General description of health care services shared: VA hospital serves
VA and DOD inpatients. VA also provides certain outpatient specialty
care for DOD patients.
Joint venture: Texas: William Beaumont Army Medical Center, Fort Bliss;
El Paso VA Health Care System;
Host agency: DOD;
General description of health care services shared: Army hospital
serves DOD and VA inpatients. Army also provides certain outpatient
specialty care for VA patients.
[A] The sharing agreement for these clinics is between the Naval
Hospital Jacksonville and the Miami VA Medical Center.
[B] Pharmacy services are the primary focus of this sharing agreement,
but VA also provides limited specialty care to DOD patients.
Source: VA and DOD joint venture site documents and officials.
[End of table]
In addition to referred patients, joint ventures, like other VA and DOD
facilities, share dually eligible patients. Recent changes in VA‘s and
DOD‘s health care programs have increased both the number of dual
eligibles and the likelihood that they will obtain services from both
systems. The number of veterans, including all military retirees,
eligible for VA health care was increased in fiscal year 1999 due to
removal of statutory restrictions.[Footnote 6] In addition, the number
of military retirees eligible for DOD health care increased in 2001
when full eligibility was extended to retirees age 65 and over.
[Footnote 7] Furthermore, a February 2002 increase in VA‘s copayment
for outpatient drugs”from $2 per prescription to $7 per
prescription”has given dual eligibles who receive health care from VA
more incentive to have their prescriptions filled at a DOD pharmacy.
[Footnote 8]
Medication Errors Pose Significant Risk:
The Institute of Medicine (IOM) raised national awareness of the problem
of medication errors with its 2000 study, To Err is Human: Building a
Safer Health System.[Footnote 9] As we reported in 2000, there is
general agreement that medication errors are a significant problem,
although the actual magnitude of the problem is uncertain. [Footnote
10] Researchers and patient safety advocates have suggested certain
measures to reduce the risk of medication errors, and VA and DOD have
incorporated many of these measures as features of their health care
systems. Figure 1 illustrates the typical process, including safeguards
that VA and DOD use to provide medications to patients.
Figure 1: Safeguards in Process Typically Used by VA and DOD to Provide
Medications to Their Own Beneficiaries:
[See PDF for image]
This figure is a listing of processes and safeguards, as follows:
Process: Provider reviews patient medical record;
Safeguards: Access to medical information: Medications, laboratory
results, and other medical information available to inform medication
decisions; safeguard applies.
Process: Provider selects drug from own agency's formulary;
Safeguards: Benefits of formulary system: Provider familiar with drugs,
side-effects, and other characteristics; safeguard applies.
Process: Provider electronically orders drug;
Safeguards: CPOE[A]: Prescription is legible, pharmacy does not have to
re-enter prescription; Alerts, reminders, and other clinical decision
support given to provider to ensure accurate prescription; safeguard
applies.
Process: Drug allergy and interaction checks are performed;
Safeguards: Allergy/interaction checks: Patient information checked for
drug allergies; Medication checked for adverse interactions; safeguard
applies.
Process: Pharmacist reviews and dispenses drug;
Safeguards: Access to medical information: Pharmacist reviews
prescription against patient's medical records; safeguard applies.
Process: Patient's medical record is documented that the drug was
dispensed;
Safeguards: Patient medical record documented; Patient medical record
updated to reflect prescription; safeguard applies.
[A] At most DOD MTFs, DOD providers lack the capability to
electronically order medications for inpatients.
Source: VA and DOD headquarters officials and joint venture site
documents and officials.
[End of figure]
Medication safety experts have identified the following factors that can
contribute to reducing medication errors.
Accessible Patient Medical Information:
According to experts from organizations such as the American Society of
Health-System Pharmacists (ASHP) and IOM, access to patient medical
information is important to both providers and pharmacists in reducing
medication errors. A study of adverse drug events conducted by Brigham
and Women‘s Hospital found that the inaccessibility of patient
information”such as information on the patient‘s condition, results of
laboratory tests, and current medications”was a leading cause of
prescribing errors.[Footnote 11] The ASHP guidelines for preventing
hospital medication errors state that prescribers should evaluate the
patient‘s total status and review all existing drug therapy before
prescribing new or additional medications. They also recommend that
pharmacists and others responsible for processing drug orders should
have routine access to appropriate clinical patient
information”including medication and allergy profiles, diagnoses, and
laboratory results”to help evaluate the appropriateness and efficacy of
medication orders. One way to provide this ready access is a
computerized medical record. A computerized medical record can improve
health care delivery by providing medical personnel with better data
access, faster data retrieval, and more versatility in data display
than available with a paper record.[Footnote 12]
Both VA and DOD are in the process of transitioning from paper-based to
electronic systems for recording and accessing patient health
information. VA‘s system, the Computerized Patient Record System
(CPRS), captures a wide range of patient information, including
progress notes, vital statistics, laboratory results, medications, drug
allergies, and radiological and catheterization images. DOD‘s system,
the Composite Health Care System (CHCS), captures similar, but less
extensive, patient information. For example, CHCS cannot capture or
store progress notes or electronic images.[Footnote 13]
Formulary Systems:
JCAHO standards for hospitals and ambulatory health organizations
require that organizations maintain formularies and direct that they
must consider the potential for medication errors as a criterion for
selecting drugs that will be stocked.[Footnote 14] Although frequently
considered a mechanism for controlling costs, patient safety experts
maintain that formulary systems can also optimize therapeutic outcomes
and facilitate medication safety.[Footnote 15] According to IOM, a
formulary system can help reduce adverse drug events because the drugs
selected for the formulary are evaluated by knowledgeable experts and
chosen based on their relative therapeutic merits and safety.[Footnote
16] In addition, formularies limit unneeded variety in drug use”a
practice supported by ISMP and the Institute for Healthcare
Improvement”and assist in educating prescribers on safe and appropriate
use of formulary drugs.
Both VA and DOD have formulary systems. VA‘s national formulary
consists of about 1,200 pharmacy items, including over 1,000 drugs, and
each of VA‘s 21 regional Veterans Integrated Service Networks can
augment the national formulary. DOD‘s Basic Core Formulary consists of
about 165 drugs, and an MTF can add other drugs based on the clinical
services and scope of care provided by that facility.[Footnote 17] Both
agencies also have approval processes for prescribers to obtain
nonformulary drugs for their patients when medically necessary. As part
of their ordering systems, some VA and DOD facilities have also
developed electronic decision-making support related to their
formularies, such as prompts to remind physicians to order specific
laboratory tests prior to administering certain drugs or alerts related
to the safe use of certain drugs.
Computerized Provider Order Entry:
CPOE systems can reduce medication errors by eliminating legibility
problems of handwritten orders and providing clinical decision-making
support by sending alerts and instantaneous reminders directly to
providers as orders are being placed.[Footnote 18] For instance, as
providers enter a medication order, they can be given a potential range
of doses for medications ordered, alerted to relevant laboratory
results, and prompted to verify which medication is being ordered when
the drug sounds or looks like another drug on the formulary. Studies
have shown computerized provider ordering reduced medication errors by
55 percent to 86 percent.[Footnote 19] In light of this evidence, the
Leapfrog Group for Patient Safety adopted computerized provider order
entry as one of its initial safety standards. ISMP has also emphasized
the need to take advantage of electronic ordering technology, calling
for the elimination of handwritten prescriptions nationwide by 2003.
VA and DOD acknowledge the safety benefits of providers electronically
ordering medications, and both CPRS and CHCS (for outpatient
prescriptions only at most locations) have this capability.[Footnote
20] VA established a goal in its 2002 Network Performance Plan for 95
percent use of CPOE (both inpatient and outpatient) by 2002, with 100
percent use planned for 2004.[Footnote 21] While DOD officials told us
that CPOE is encouraged and widely utilized, DOD has no written policy
or goals related to its use.
Automatic Checks for Drug Interactions and Allergies:
Both VA‘s and DOD‘s electronic ordering systems perform automatic
checks for potential adverse reactions due to drug allergies and
interactions. VA‘s CPRS performs checks for drug allergies and
interactions between all medications ordered and dispensed by a VA
facility, including those sent from VA‘s mail order center. Although
medications dispensed for the same patient at another VA facility are
generally not included in the check, VA officials told us that they are
exploring methods to broaden their drug interaction capability.
[Footnote 22] DOD‘s system for drug interaction checking is more
comprehensive than VA‘s system. CHCS checks for drug allergies and
interactions between drugs prescribed or dispensed at the MTF, and
DOD‘s Pharmacy Data Transaction Service (PDTS) aggregates information
from CHCS with other points of service”other MTFs, network pharmacies,
and DOD‘s mail order pharmacy”to perform a complete drug interaction
check.[Footnote 23]
Automatic electronic checks for drug interactions, commonly available in
retail drug stores, have been shown to greatly minimize medication
errors. [Footnote 24] For example, one study found that an automated
review of prescriptions written for 23,269 elderly patients produced
43,007 alerts warning about potential medication problems”24,266 of
which recommended a change in drug or dosage.[Footnote 25] Professional
groups such as ASHP and ISMP have also acknowledged the value of these
systems.
Shared Patients Obtain Inpatient Drugs from the Treating Agency but
Generally Return to Home Agency for Outpatient Drugs:
At the six joint venture sites where inpatient services are provided,
all patients referred for inpatient care receive medications from the
inpatient facility providing the care.[Footnote 26] Processes used to
provide and record inpatient medications to referred patients are the
same as those used for the host agency‘s own beneficiaries. Inpatient
medications are ordered using the host facility‘s formulary guidelines
and filled through the inpatient pharmacy. Initial supplies of
discharge medications (usually 30 days or less) are also typically
provided, although patients are expected to return to their home agency
pharmacy for longer-term supplies.
In contrast, the process for providing medications to shared outpatients
differs across sites. At six of the joint venture sites, each agency
maintains a separate outpatient pharmacy. As a general rule, each
agency expects its beneficiaries to use its pharmacy for outpatient
prescriptions, even when providers from the other agency order the
prescription. For instance, in Hawaii, both the Tripler Army Medical
Center and the VA outpatient clinic next door maintain outpatient
pharmacies. VA patients who are referred to Tripler for outpatient
specialty care are expected to return to the VA clinic pharmacy to have
their prescriptions filled. Even though this is the general rule at
most sites, we noted that exceptions occur. For instance, at David
Grant Medical Center on Travis Air Force Base, DOD supplies oncology
medications to VA patients. Another exception is that all joint venture
inpatient facilities provide weekend and after-hours emergency room care
to patients of the other agency and, generally, medications are also
supplied if needed. In contrast to the general rule, at the DOD
facility in El Paso, referred VA patients are not expected to return to
their home agency for their initial prescriptions but rather are
allowed to obtain an initial supply of drugs from the DOD pharmacy.
Subsequent prescriptions for these patients (renewals or refills) must
be filled by their VA pharmacy.
At the seventh site, Key West, only DOD maintains a pharmacy. It serves
both VA and DOD patients. However, VA patients receive only initial,
short-term prescriptions (up to 30 days) from this DOD pharmacy and
obtain longer-term prescriptions and refills via mail from the VA
Medical Center in Miami.[Footnote 27]
Shared Patients Experience Gaps in Medication Safety Measures:
VA‘s and DOD‘s separate, uncoordinated information and formulary
systems result in gaps in medication safeguards for shared inpatients
and outpatients. Lacking coordinated information systems, providers and
pharmacists at joint venture sites often cannot access shared patients‘
complete health information, including prescribed medications, nor can
providers from one agency use electronic ordering to prescribe drugs
that are to be dispensed by the other agency‘s pharmacy. Because
information systems are uncoordinated, checks for drug allergies and
interactions for shared patients are based on incomplete information.
In addition, separate formulary systems introduce complications for
shared patients because providers must either prescribe from the other
agency‘s formulary, which may contain drugs unfamiliar to providers, or
prescribe a limited supply of a drug, which may later be switched to
comply with the formulary of the patient‘s home agency. These gaps are
illustrated in figure 2.
Figure 2: Gaps in Medication Safeguards for Shared Patients:
[See PDF for image]
This figure is an illustration of gaps in medication safeguards for
shared patients, as follows:
Process: Beneficiary is referred to other agency for care;
Process: Treating physician reviews referral information and orders
any needed medication;
Safeguard: Access to medical information: Treating physician does not
have access to medical record; [A gap in the safeguard under this
process].
Where is the prescription filled? Patient's home agency:
Process: Physician selects drug from formulary of patient's home
agency;
Safeguard: Benefits of formulary; Physician may be prescribing an
unfamiliar drug; [A gap in the safeguard under this process].
Process: Physician handwrites or prints out order and prescription goes
to the patient's home pharmacy;
Safeguard: CPOE: Potential for legibility problems; [A gap in the
safeguard under this process].
Process: Home pharmacy personnel types order into ordering system;
Safeguard: CPOE: Potential for data re-entry problems; [A gap in the
safeguard under this process].
Process: System performs local drug interaction and allergy checks
against other drugs prescribed/filled by home agency;
Safeguard: CPOE: Warning does not go to the prescribing physician; [A
gap in the safeguard under this process].
Process: Pharmacist reviews and dispenses prescription.
Process: Patient's home record documented that medication was
dispensed.
Where is the prescription filled? Treating agency:
Process: Physician selects drug from formulary of physician's agency.
Process: Physician orders medication electronically.
Process: Prescribed medication undergoes automatic drug interaction and
allergy checks against other drugs prescribed by treating agency;
Safeguard: Allergy/interaction checks: Incomplete drug interaction check
Allergy information likely to be in patient's home record; [A gap in
the safeguard under this process].
Process: Pharmacist reviews and dispenses prescription
Safeguard: Access to medical information: Pharmacist's review is
weakened by lack of patient medical information; [A gap in the
safeguard under this process].
Process: Patient record documented at treating agency that medication
was dispensed;
Safeguard: Patient medical record documented; Home agency record may
not be updated to show drug ordered or dispensed; [A gap in the
safeguard under this process].
Note: This figure depicts the general process for shared inpatients and
outpatients. However, an additional gap exists for shared inpatients
that is not illustrated in the figure. Shared patients who are taking
medications at the time of admission may have those drugs switched to
comply with the agency‘s formulary at the inpatient facility.
Source: VA and DOD joint venture site documents and officials.
[End of figure]
Providers and Pharmacists Have Incomplete Access to Health and
Medication Information on Shared Patients:
Ready access to pertinent clinical information is an important feature
of medication safety; while VA‘s and DOD‘s patient information systems
are capable of serving this function for each agency‘s own
beneficiaries, gaps exist for shared patients. VA and DOD providers and
pharmacists have ready access to health records of their own
beneficiaries, largely through CPRS and CHCS, respectively. However,
when agencies refer patients for care, the treating agency‘s providers
and pharmacists have incomplete access to patients‘ health and
medication information. Although referrals will usually be accompanied
by some explanation of patients‘ medical conditions, the bulk of their
electronic health and medication information, which resides in the
health information system of their home agency, will often not be
available to providers and pharmacists in the agency where they are
referred for care. Access for pharmacists and treating providers to
patient information in the referring agency‘s information system varies
by location. For example, at four joint venture sites, pharmacists
filling prescriptions for shared patients have no access to the other
agency‘s patient information system. At another site, pharmacy access is
restricted”at Tripler Army Medical Center in Hawaii, access to VA‘s CPRS
is available in the inpatient pharmacy, but only one pharmacist has
access. Providers at a few facilities have broader access. For example,
at the David Grant Medical Center at Travis Air Force Base in northern
California, CPRS is installed on every network computer that has CHCS,
and providers in certain departments have been granted CPRS access.
VA and DOD pharmacists and providers we spoke with noted that lack of
relevant patient health information could be a problem for shared
patients. One example given to us was a VA provider treating a dual-
eligible patient for diabetes. Certain drugs cannot be safely
prescribed for diabetics without monitoring through laboratory tests.
If the patient receives care from a VA physician but has prescriptions
filled at a DOD pharmacy, the pharmacist would be unable to access the
patient‘s medical record to review these laboratory results. [Footnote
28] Without this access, the pharmacist must call VA to ensure these
laboratory values are within normal limits. In addition, pharmacy
personnel at Tripler in Hawaii, where a single inpatient pharmacist has
CPRS access, told us that additional pharmacists need CPRS access to
facilitate after-hours medication needs of VA patients when this
pharmacist is unavailable.
Providers Generally Cannot Electronically Prescribe Drugs for Shared
Patients:
Computerized provider ordering of medications increases safety by
assisting with medication decisions, providing alerts for drug
interactions and allergies, and obviating handwriting legibility and
transcription problems. However, prescriptions for shared patients are
less likely to be ordered electronically by providers. Although both VA
and DOD providers have outpatient electronic ordering capabilities when
prescriptions are dispensed at their own pharmacies, patients referred
from one agency to the other for care are typically expected to return
to their home pharmacy to get prescriptions filled.[Footnote 29] With
the exception of DOD providers in Hawaii, none of the joint venture
sites have the capability for providers to electronically order
medications through their own computer systems for drugs that are to be
dispensed by the other agency‘s pharmacy, nor do they typically have
access to the other agency‘s electronic ordering systems to issue
medication orders. Consequently, providers either handwrite medication
orders for shared patients or give them printed copies that must be
retyped into the patients‘ home agency‘s pharmacy system. Both
situations introduce risks unique to shared patients.
We also found situations where providers had the capability to avoid
handwriting prescriptions but continued to handwrite them. In Key West,
for example, where all drugs are dispensed from the DOD pharmacy, VA
providers have access to DOD‘s electronic ordering system, CHCS; but,
for the most part, they handwrite prescriptions. These providers record
patient care and medications in VA‘s CPRS, and if they were to
electronically order medications, it would necessitate entry into a
second system. They told us that using CHCS was slow and cumbersome, and
ordering the medications using it took too much time.[Footnote 30] A VA
provider in Hawaii told us that, for these same reasons, providers
sometimes handwrote prescriptions for dual eligibles to have filled at
the DOD pharmacy when only one or two medications were being ordered.
Finally, although VA patients benefit when providers electronically
order medications in VA hospitals, they generally lose this benefit
when referred to DOD hospitals. Providers in VA hospitals have
electronic ordering capability for inpatient medications, but this
capability is not generally available in DOD hospitals. VA patients
referred to DOD hospitals, like DOD‘s own beneficiaries, usually have
their prescriptions handwritten by the provider, and then manually
entered into CHCS by pharmacy personnel. Thus, these patients are
subjected to the risks associated with handwritten prescriptions, such
as illegible orders and transcription errors.
Incomplete Record of Patient Medications Hinders Automatic Checks
for Drug Interactions and Allergies:
Shared patients also do not get the full benefit of VA‘s and DOD‘s
automatic checks for drug allergies and interactions. VA and DOD
patients who receive all their medications through only one health care
system will have comprehensive medication histories stored in either
CPRS or CHCS (in conjunction with PDTS). When the medication is
ordered, CPRS or CHCS/PDTS will perform automatic checks for drug
allergies and interactions. However, if patients are taking medications
obtained from both agencies, neither agency‘s record of patient
medications is complete at any joint venture site. Thus, when
interaction checks are done, they will be incomplete for shared
patients because the checks are restricted to the information available
within each system. Likewise, providers may be unaware of drug
allergies. For example, when a patient who routinely gets health care
at the VA clinic in El Paso is referred to the Army Medical Center for
outpatient specialty care, the DOD pharmacy will fill a prescription
for up to 30 days of medications. However, when the pharmacy performs
its automatic checks, drug allergies may not be detected because
information on drug allergies is likely to be in VA‘s CPRS where the
bulk of the patient‘s clinical information is stored, not in CHCS/PDTS
where the drug check will occur. In its interim report, the President‘s
Task Force to Improve Health Care Delivery for Our Nation‘s Veterans
stated that the instances of adverse drug events might be substantially
reduced for shared patients through use of a comprehensive screening
tool like PDTS and plans further analysis in this area for its final
report.[Footnote 31]
Because VA and DOD each has its own formulary system, providers who
treat referred patients sometimes prescribe from the referring agency‘s
formulary and sometimes from their own facility‘s formulary, depending
on where the prescription will be filled. Unless the prescribed drug is
common to both formularies, each situation limits the medication safety
benefits of a formulary system, such as increased provider familiarity
with drugs prescribed and the added safety net provided by clinical
decision support. The President‘s Task Force to Improve Health Care
Delivery for Our Nation‘s Veterans noted that a joint VA/DOD formulary
could combine the clinical expertise of both VA and DOD and improve
patient safety.
Providers who use the other agency‘s formulary in prescribing for shared
patients and find that the drug they would normally prescribe is not
listed are disadvantaged in several ways. First, according to formulary
system principles endorsed by the American Medical Association, ASHP,
and others, one characteristic of a formulary system should be that the
pharmacy and therapeutics committee educates providers about drugs on
the formulary. A senior official from ISMP told us that provider drug
knowledge is also reinforced by a formulary system because formularies
limit the number of drugs providers need to be knowledgeable about.
Consequently, providers should be less likely to make mistakes in drug
selection or dosage when prescribing formulary drugs. Second, when
prescribing a drug that is not on their formulary, providers may lose
the clinical support capabilities that may be built into their agency‘s
CPOE system. For example, the medication error prevention committee at
Tripler in Hawaii evaluates Tripler‘s formulary drugs for safety
problems and designs safeguards into CHCS, such as distinctive
lettering to alert providers to drug names that look alike or sound
alike. However, DOD providers typically try to prescribe for VA
outpatients using VA‘s formulary. Consequently, this safeguard is lost
to the shared patient.
Providers usually prescribe from their own facility‘s formulary for a
referred patient if the prescription is to be filled at their facility‘s
pharmacy. For instance, at all joint venture sites, referred inpatients
receive short-term supplies of discharge medications at the host
facility‘s pharmacy. If patients need longer-term supplies of
medications or refills, they typically are expected to return to their
home pharmacy. This situation can also put patients at risk if the
original medication is not on the formulary at their home pharmacy. For
instance, in Key West, VA physicians write VA patients two different
prescriptions: one for their initial supply to be filled at the joint
venture‘s DOD pharmacy and a second for a longer-term supply that is
mailed from the VA Medical Center in Miami. One VA physician told us
that when a VA formulary drug he wants to prescribe is not on the DOD
formulary, he prescribes an equivalent drug carried by the DOD pharmacy
for the short term and orders the VA formulary drug from Miami to use
on a long-term basis. Experts agree that such interchanging of drugs in
a therapeutic class may sometimes cause problems because differences in
individual physiology make some people react differently to a very
similar therapeutic agent. Although such interchange is an accepted
practice in formulary systems, when physicians are able to avoid
switching drugs, they reduce the risk that an adverse reaction will
occur.
Safety Gaps Remain Despite Efforts to Address Them:
Recognizing these risks for shared patients, joint venture facilities
have undertaken efforts intended to address these safety gaps. However,
none of these efforts fully solve the problems that exist, nor are they
all used at any site.
All joint venture sites have taken steps to increase access to patient
information. For example, at Tripler in Hawaii, VA and DOD recently
added VA‘s CPRS to computers in the DOD hospital so that VA physicians
monitoring the care of VA inpatients would have electronic access to
patients‘ VA health records. However, at the time of our visit, most DOD
physicians were unaware that the capability to access CPRS existed, and
DOD officials at Tripler had no plans to promote its use or to provide
training. Similarly, some physicians at all other joint ventures have
access to both systems; but, as in Hawaii, this access is generally
limited in the number of computers that have this capability and the
number of providers who have been authorized to use it. For instance,
access to both systems is available at some locations in the Mike
O‘Callaghan Federal Hospital in Nevada, but VA pharmacy officials at
the VA outpatient clinic in this joint venture told us that the lack of
such access in the clinic presented a major problem. They told us that
not having access to such patient information as test results and
physician notes made it difficult for them to research questions about
patients‘ medications. Only two sites have pharmacies with access to
the other agency‘s patient information system; access is very limited
at one of those sites”at Tripler, only one pharmacist has been
authorized to use CPRS. Furthermore, medical personnel who had access
told us that its use is hindered by their lack of familiarity with the
other agency‘s system and by the difficulties of accessing separate,
dissimilar systems.
Recognizing the increased risks associated with handwriting
prescriptions rather than using CPOE, two joint venture sites have
devised ways to minimize this risk for shared patients. In Hawaii, VA
providers have worked out an agreement with the DOD pharmacy that they
will provide dual beneficiaries a computer-printed copy of the
electronic order, called an ’action profile,“ which the pharmacy will
accept in lieu of a handwritten order. In Hawaii”at the time of our
visit”and northern California, a printer for DOD‘s CHCS had been
installed in the VA pharmacy so that medication orders from DOD
providers could be printed out in the VA pharmacy. VA pharmacy
personnel then re-enter orders into CPRS to dispense the medications.
While these efforts remove the potential for misreading handwritten
prescriptions, they fall short of the full benefits of electronic
ordering and filling because re-entering information into CPRS
introduces the potential for transcription errors. In August 2002,
information technology personnel in Hawaii implemented an electronic
link that allows outpatient medication orders entered into CHCS for VA
patients to be transmitted directly into CPRS, eliminating the need for
manual re-entry in the VA pharmacy. Officials involved in the Hawaii
project told us that this link is working well and that this technology
was developed with the intent of transferring it to other sites. They
also told us that the project was developed with the ultimate intent
of two-way”or bi-directional”communications, so that with some
additional modification a link could be established allowing VA
physicians to send CPRS medication orders to CHCS at Tripler for
processing and filling.
Three joint venture sites have taken steps to compensate for problems
associated with drug interaction checks for shared patients. For
example, VA physicians in Hawaii told us that when they provide
prescriptions for dual eligibles to be filled at DOD‘s pharmacy, they
also enter them into VA‘s CPRS and mark them ’hold“ so that they will
not be dispensed by the VA pharmacy. Thus, checks for interactions with
other drugs prescribed by VA can be performed by CPRS, and the
patients‘ medication information will be updated to reflect the
medication orders. In Texas, VA adds information to CPRS about care and
medications provided to referred patients by DOD physicians. This
information is recorded in a special section of CPRS. When VA
physicians subsequently access patients‘ records, CPRS alerts them that
new information has been added to this section of the record, but the
information is not included in automatic drug checks. The VA clinic in
Anchorage, Alaska, uses a different approach to address the problem of
incomplete medication records. Officials there told us they have
developed software to supplement information in the CPRS record by
capturing and displaying information about drugs obtained from DOD and
other non-VA sources, including herbal supplements and over-the-counter
drugs. Thus, providers and pharmacists have additional information that
might help them prevent adverse drug interactions. However, information
collected in this way may not be accurate or complete because it
depends on patient recall and is entered manually. In addition, this
information is not accessed by CPRS‘s automatic drug checks because it
is a supplement to, not a part of, the CPRS record.
Finally, five joint ventures have instituted practices to address safety
problems related to separate formularies. For example, the Mike
O‘Callaghan Federal Hospital at Nellis Air Force Base in Nevada has a
combined P&T committee that includes both VA and DOD representatives
who select the medications that will be included on the hospital‘s
inpatient formulary. In addition, the committee approved nearly 50 VA
formulary medications to be stocked in the hospital pharmacy for use by
VA inpatients at this facility. All measures taken to improve
medication safety, such as entering reminders or alerts into CHCS to
safeguard against medication mistakes, also apply to VA drugs stocked
in the pharmacy. Other sites have undertaken less comprehensive
measures to address problems arising from separate formularies. For
instance, pharmacies at two sites stock drugs commonly prescribed for
the other agency‘s patients, but neither host agency‘s P&T committee
has representatives from both agencies. At two other sites,
representatives from both agencies are on the host agency‘s P&T
committee. While these efforts are helpful in overcoming difficulties
associated with separate formularies, none is a complete solution.
Conclusions:
As VA and DOD strive to improve efficiency and access to care through
greater collaboration and sharing of resources, it is likely that the
number of patients who receive care from both systems will increase.
Consequently, the safety of shared patients merits continuing concern.
While our findings are based on the joint venture sites, they may have
relevance wherever patient care is shared between VA and DOD.
Some joint ventures have taken steps to address medication safety
problems for shared patients, but these steps are partial solutions and
gaps remain. For example, facilities have provided only limited access
to the other agency‘s patient medical information system and have not
always provided training in its use. Therefore, providers do not have
adequate access to patient medical information for shared patients, and
lacking the comprehensive capability afforded by a system like PDTS,
they can perform only incomplete checks for drug interactions and
allergies. In addition, when shared patients return to their home
agency to have prescriptions filled, providers give them handwritten or
computer-printed prescriptions, rather than electronically ordering
medications, creating risk for legibility or transcription errors.
Furthermore, separate P&T committees may be unable to effectively
overcome problems that arise from separate formularies. The measures
already taken by some joint ventures show that risks that shared
patients face can be addressed. VA and DOD could develop systemwide
rather than local solutions to address the needs of shared patients
nationally as well as at the joint venture sites.
Recommendations For Executive Action:
To better protect shared patients at the joint ventures, we recommend
that the Secretary of Veterans Affairs direct the Under Secretary for
Health and that the Secretary of Defense direct the Assistant Secretary
of Defense for Health Affairs to:
* develop the capability for VA and DOD providers to access patient
medical information relevant to medication decision making, regardless
of whether that information resides in VA‘s or DOD‘s information system
and provide training to physicians and pharmacists who need to use this
access;
* develop the capability to perform a comprehensive, automatic drug
interaction check that uses medication information from all VA and DOD
facilities and mail order operations and DOD‘s network pharmacies, and
evaluate the potential for DOD‘s PDTS to be used for this purpose;
* require providers to use computerized order entry of medications for
shared patients where it is available and implement system modifications
that will enable providers to electronically order medications to be
dispensed at the other agency‘s pharmacies; and;
* establish a joint VA and DOD pharmacy and therapeutics committee, or
similar working group, at each joint venture site to determine how best
to safely meet the medication needs of VA and DOD shared patients and to
overcome obstacles associated with separate formularies.
Agency Comments and Our Evaluation:
The Department of Veterans Affairs and the Department of Defense
provided written comments on a draft of this report. These comments are
discussed below and reprinted in appendix I and appendix II,
respectively. VA concurred with all our recommendations, while DOD
concurred with two of our recommendations, partially concurred with
one, and did not concur with one.
Both VA and DOD concurred with our recommendation to develop the
capability for VA and DOD providers to access patient medical
information in both CPRS and CHCS. In their comments, both agencies
discussed longer-term solutions, such as the joint VA-DOD Federal
Health Information Exchange (FHIE) initiative.[Footnote 32] While we
support long-term efforts that would lead toward a more seamless
sharing of information between VA and DOD, we believe that a number of
joint venture sites have demonstrated that interim steps, such as
giving providers access to and training on the other agency‘s system,
are both warranted and feasible.
Both agencies also concurred with our recommendation regarding the
development of comprehensive, automatic drug interaction checks,
including the evaluation of PDTS for this purpose. VA stated that this
capability would be accomplished with the second phase of the VA-DOD
joint plan, called HealthePeople (Federal), which VA expects to be
implemented in fiscal year 2005. Although agreeing to evaluate the cost
benefit of adopting PDTS, VA said that, based on VA and DOD workload
data, a relatively small number of veterans had been treated in both
systems in the period from October 2001 through May 2002 (240,716
unique patients, or 29.6 percent of all dual eligibles) and raised the
issue of whether the cost of PDTS was justified for so few cases. We
believe this almost quarter of a million patients represents a
significant opportunity for adverse drug events to occur, especially
since, based on the prescription patterns of a typical VA patient, this
group received an estimated 4 million prescriptions in this 8-month
period.[Footnote 33] Furthermore, the number of patients potentially at
risk is larger than the dual eligible group. It includes an unknown
number of patients who receive care and medications from both agencies
under VA-DOD resource sharing agreements. While we agree that cost is
an important factor, we believe the large number of prescriptions for
these patients justifies an evaluation of PDTS that considers both cost
and patient safety.
VA concurred and DOD partially concurred with our recommendation on
CPOE. VA said it has already planned for its providers to use
computerized order entry for all orders, including medications, by
fiscal year 2004. It also made reference to the Hawaii pilot project
discussed earlier in this report as a way of extending this capability
for shared patients but said that a more robust bi-directional
capability would be included as a systems requirement in the
HealthePeople (Federal) effort. DOD also agreed to require that
providers use CPOE for shared patients where available; however, it did
not agree with system modifications as the approach for extending this
capability. Instead, DOD advocated the joint procurement of a
commercial off-the-shelf pharmacy information system. It said that this
approach would provide greater economic returns and system
interoperability since both agencies are pursuing plans to upgrade or
replace their pharmacy information system modules. We agree with this
approach as a longer-term solution. However, agency officials told us
that neither agency has plans to upgrade or replace its system until
fiscal year 2005 at the earliest, leaving shared patients at continued
risk for medication errors until the new system is operational. System
modifications already accomplished in Hawaii indicate that interim steps
toward reducing these risks are possible.
VA concurred with our recommendation on establishing a joint P&T
committee or similar working group at each joint venture site and said
it would pursue this recommendation via the VA/DOD Executive Committee,
a working group for VA/DOD collaboration issues. DOD did not concur
with establishing a joint P&T committee at each site; however, we
recommended the establishment of a joint VA-DOD group, either a P&T
committee or a similar working group, that would determine how best to
safely meet the medication needs of shared patients at each site. DOD
expressed support for the already-established working groups, but, as we
have noted, only three joint venture sites have such collaborative
groups.
We are sending copies of this report to the Secretary of Veterans
Affairs, the Secretary of Defense, and other interested parties. Copies
will also be made available to others on request. In addition, the
report is available at no charge on the GAO Web site at [hyperlink,
http://www.gao.gov]. If you or your staff have any questions about this
report, please contact me at (202) 512-7101. Other contacts and major
contributors are listed in appendix III.
Sincerely yours,
Signed by:
Cynthia A. Bascetta:
Director, Health Care”Veterans‘ Health and Benefits Issues:
[End of section]
Appendix I: Comments from the Department of Veterans Affairs:
The Secretary Of Veterans Affairs:
Washington:
September 13, 2002:
Ms. Cynthia A. Bascetta:
Director, Health Care-Veterans' Health and Benefits Issues:
U.S. General Accounting Office:
441 G Street, NW:
Washington, DC 20548:
Dear Ms. Bascetta:
The Department of Veterans Affairs (VA) has reviewed your draft report,
VA And Defense Health Care: Increased Risk of Medication Errors for
Shared Patients (GAO-02-1017) and agrees with your findings and
conclusions and concurs with your recommendations. VA is pleased to
report that actions are already underway to implement them through
collaborating with the Department of Defense (DOD).
Of paramount importance to VA is continued excellence in providing
needed health care to our nations veterans. Part of providing quality
health care is the assurance that prescribed medications be safe as
well as efficacious. As VA expands its joint ventures with DOD, VA will
work closely with its DOD colleagues to assure the continued level of
safety to all patients the Department serves as well as the veterans
the DOD serves through its health care systems.
Thank you for the opportunity to comment on your draft report.
Sincerely yours,
Signed by:
Anthony J. Principi:
Enclosure:
The Department Of Veterans Affairs Comments To GAO Draft Report, VA And
Defense Health Care: Increased Risk of Medication Errors for Shared
Patients (GAO-02-1017):
GAO recommends that I:
* Develop the capability for VA and DOD providers to access patient
medical information relevant to medication decision making, regardless
of whether that information resides in VA's or DOD's information system
and provide training to physicians and pharmacists who need to use this
access;
Concur - The Departments of Veterans Affairs (VA) and Defense (DOD)
have developed a close collaborative partnership, under the titles of
the Federal Health Information Exchange (FHIE) and HealthePeople
(Federal). Under this partnership, the agencies are exchanging data and
developing a common health information infrastructure and architecture
comprised of standardized data, communications, security, and high
performance health information systems.
VA and DOD are jointly implementing a plan that will result in
computerized health record systems that ensure interoperability between
DOD's CHCS II (Composite Health Care System) and VA's HealtheVet
strategy for VistA (HealtheVet-VistA) by FY 2005. Using clinical
decision support applications, providers of care in both Departments
will be able to access and use the relevant medical information to aid
them in making medication decisions for their patients regardless of
whether that information resides in VA's or DOD's information systems.
Because the providers will use the information systems that they use
within their own institutions on a routine basis, no significant
additional training will be necessary to access this relevant
information.
* Develop the capability to perform a comprehensive, automatic drug
interaction check that uses medication information from all VA and DOD
facilities and mail order operations and DOD's network pharmacies,
including an evaluation of the potential for DOD's Pharmacy Data
Transaction Service to be used for this purpose;
Concur - When the second phase of the joint plan - HealthePeople
(Federal) - is implemented in FY 2005, VA and DOD will have the
capability to perform comprehensive automatic drug interaction checks
using medication information from all VA and DOD facilities and mail
order operations and DOD's network pharmacies. This will be possible by
providing interdepartmental access, when appropriate, to medical
information residing in the two departmental data repositories.
This interoperability will provide the two Departments the capability
to perform checks on drug-drug interactions and duplicate drug class
orders that are available in DOD's Pharmacy Data Transaction Service.
It will allow the Agencies to perform the clinically important drug
allergy and drug adverse event checks as well.
During the interim period before full implementation of the proposed
joint health information systems, VA will continue to work closely with
DOD in identifying feasible opportunities to maximize mutual access to
patient medical information. It should be noted, however, that the cost
benefits of any supplemental approach must be carefully considered.
Recent information compiled from VA and DOD workload databases identify
240,716 patients (29.6 percent of all dual eligible patients) who
received prescriptions from both VA and DOD between October 1 2001, and
May 31, 2002. Of the approximately 3.5 million unique veterans who
receive prescription benefits from VA, only 6.8 percent are dual
eligible. This represents a relatively small number of veterans treated
in both systems, and raises the issue of whether a costly partial
solution could be justified for so few cases, especially when there are
no data presented to indicate that out-of-line medication errors have
been reported for the shared patients. VA will explore the cost benefit
of adopting DOD's PDTS. Nevertheless, even in this system, it is
possible to correctly prescribe and dispense a drug without being able
to access important information about allergies or previous adverse
events. Any robust clinical system, such as the proposed DOD Clinical
Data Repository and VA Health Data Repository, should have these
capabilities.
* Require providers to use computerized order entry of medications for
shared patients where it is available and implement system
modifications that will enable providers to electronically order
medications to be dispensed at the other agency's pharmacies;
Concur - VA has already planned for providers to use computerized order
entry for all orders including medications by FY 2004.
VA is conducting a pilot project in Honolulu that allows outpatient
prescriptions entered at Tripler Army Medical Center to be
electronically transferred to the VistA system at Spark Matsunaga VA
Medical Center. These orders undergo the same order checks as any other
VistA order, and are included for display on the patient's VistA
profile. Production testing is underway at these facilities now, and so
far the results are very favorable.
A similar but more robust bi-directional capability will be included as
a systems requirement in the HealthePeople (Federal) effort now
underway between VA and DOD.
* Establish a joint VA and DOD pharmacy and therapeutics committee or
similar working group at each joint venture site to determine how best
to safely meet the medication needs of VA and DOD shared patients and
to overcome obstacles associated with separate formularies.
Concur - VA will pursue this recommendation via the VA/DOD Executive
Committee. Since VA has successfully established a comprehensive
national formulary system, which includes the VISN formularies as well
as the VA National Formulary, VA proposes that VA's national formulary
be the model for the joint formulary at each venture site. The
formulary could be augmented with DOD-specific medication requirements
that can be addressed through a joint local pharmacy and therapeutics
committee.
[End of section]
Appendix II: Comments from the Department of Defense:
The Assistant Secretary Of Defense:
Health Affairs:
Washington, D.C. 20301-1200:
September 17, 2002
Ms. Cynthia A. Bascetta:
Director, Health Care-Veterans' Health and Benefits Issues:
U.S. General Accounting Office:
Washington, DC 20546:
Dear Ms. Bascetta:
This is the Department of Defense (DoD) response to the General
Accounting Office (GAO) draft report GAO-02-1017, "VA And Defense
Health Care: Increased Risk Of Medication Errors For Shared Patients,"
dated August 19, 2002 (GAO Code 290163).
GAO Recommendation: To better protect shared patients at the joint
venture sites, develop the capability for Veterans Affairs (VA) and DoD
providers to access patient medical information relevant to medication
decision making, regardless of whether that information resides in VA's
or DoD's information system and provide training to physicians and
pharmacists who need to use this access.
DoD Response: The Department concurs with the recommendation.
Initiatives such as the Federal Health Information Exchange (FHIE) are
already providing various patient health data to the VA. This is
scheduled to include pharmacy data by 2nd Quarter Fiscal Year 2003. For
the long-term, DoD and VA are working to establish interoperability
between their respective electronic health information systems to
further enhance the exchange of patient health information thereby
improving the effectiveness of the health care delivery at joint
venture sites. Before this can be implemented, issues such as
credentialing, privileging, reimbursement for goods and services,
security (including background checks on personnel), and Health
Insurance Portability & Accountability Act (HIPAA) privacy requirements
must be addressed.
GAO Recommendation: Develop the capability to perform a comprehensive,
automatic drug interaction check that uses medication information from
all VA and DoD facilities and mail order operations and DoD's network
pharmacies, including an evaluation of the potential for DoD's Pharmacy
Data Transaction Service to be used for this purpose.
DoD Response: The Department concurs with both aspects of the
recommendation at joint venture sites, i.e., to develop an automatic
interaction check to include information from all VA and DoD dispensing
facilities, mail order operations, and DoD's retail network pharmacies;
and, concur with an evaluation of the potential for the VA to use DoD's
Pharmacy Data Transaction . service for this purpose.
GAO Recommendation: Require providers to use computerized order entry
of medications for shared patients where it is available and implement
system modifications that will enable providers to electronically order
medications to be dispensed at the other agency's pharmacies.
DoD Response: The Department concurs with the recommendation to require
all DoD/VA providers to use computerized order entry (CPOE) for
medications for shared patients where CPOE is available. However, the
Department non-concurs with the recommendation to implement systems
modifications as the approach for resolution of accepting CPOE
medication requests by each Department. It is the Department's opinion
that such an approach would waste resources and falls short of
providing total interoperability of both agencies' pharmacy operations.
Since both Departments are pursuing upgrades or replacements to their
respective Pharmacy information system modules, a joint procurement
strategy for a commercial off-the-shelf (COTS) pharmacy information
system provides greater economic returns and total interoperability
independent of whichever CPOE system is used to transmit the medication
order.
GAO Recommendation: Establish a joint VA and DoD pharmacy and
therapeutics committee, or similar working group, at each joint venture
site to determine how best to safely meet the medication needs of VA
and DoD shared patients and to overcome obstacles associated with
separate formularies.
DoD Response: The Department non-concurs with establishing joint VA and
DoD pharmacy and therapeutics committees at each site, since VA
formulary management is controlled at the VISN and National level, and
DoD is in the process of implementing the provisions of 10 U.S.C. 1074g
that directs the Department to implement a Uniform Formulary. The
Department does concur with the recommendation to continue the
established working groups at each joint venture site to continue
exploring collaborative opportunities that ensure the appropriate and
safe use of medications for VA and DoD shared patients and to overcome
obstacles associated with each Department maintaining separate
formularies.
My point of contact on this action is Colonel William Davies, at (703)
681-0039.
Sincerely,
Signed by:
E.P. Wyatt, for:
William Winkenwerder, Jr., MD:
[End of section]
Appendix III: GAO Contacts and Staff Acknowledgments:
GAO Contacts:
Deborah L. Edwards, (202) 512-7101:
Keith E. Steck, (202) 512-9166:
Acknowledgments:
In addition to those named above, the following staff members made key
contributions to this report: Irene J. Barnett, Linda Diggs, Mary W.
Reich, Karen Sloan, and Thomas Walke.
[End of section]
Footnotes:
[1] VA and DOD could not provide us with the number of beneficiaries
receiving care under sharing agreements. However, in our 2000 report,
VA and Defense Health Care: Evolving Health Care Systems Require
Rethinking of Resource Sharing Strategies ([hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-00-52], May 17, 2000), six
joint venture sites”sites where VA and DOD have pooled resources to
capitalize on existing facilities or to build new ones”reported about
360,000 episodes of care under sharing agreements for fiscal year 1998.
[2] A formulary is a set of drugs that a health care organization
prefers that its physicians prescribe.
[3] ’Home agency“ is used in this report to refer to the primary agency
the patient relies on for care and ’treating agency“ for the other
agency. For instance, VA is the home agency for VA patients referred to
DOD for care, and DOD is the treating agency.
[4] Pub. L. No. 97-174, 96 Stat. 70 (1982) (codified to 38 U.S.C. §
8111 (2000)).
[5] U.S. General Accounting Office, VA and Defense Health Care:
Evolving Health Care Systems Require Rethinking of Resource Sharing
Strategies, [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-00-
52] (Washington, D.C.: May 17, 2000).
[6] Income restrictions were removed by the Veterans Health Care
Eligibility Reform Act of 1996, Pub. L. No. 104-262, § 101, 110 Stat.
3177, 3179 (1996). VA's implementing regulations are found at 38 C.F.R.
§§ 17.46, 17.47 (2001).
[7] Eligibility was expanded by the Floyd D. Spence National Defense
Authorization Act for Fiscal Year 2001, Pub. L. No. 106-398, §§ 711-
712, 114 Stat. 1654, 1654A-175, 1654A-176 (2000). Formerly, military
retirees 65 and older were treated on a space-available basis.
[8] This copayment is adjusted annually for inflation.
[9] IOM estimated that over 7,000 people in the United States die each
year from medication errors. Institute of Medicine, To Err is Human:
Building a Safer Health System (Washington, D.C.: National Academy
Press, 2000).
[10] U.S. General Accounting Office, Adverse Drug Events: The Magnitude
of Health Risk Is Uncertain Because of Limited Incidence Data,
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-00-21]
(Washington, D.C.: Jan. 18, 2000).
[11] Lucian L. Leape and others. ’Systems Analysis of Adverse Drug
Events,“ The Journal of the American Medical Association, vol. 274, no.
1 (1995).
[12] U.S. General Accounting Office, Medical ADP Systems: Automated
Medical Records Hold Promise to Improve Patient Care, [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO/IMTEC-91-5] (Washington, D.C.:
Jan. 22, 1991), and Institute of Medicine, The Computer-Based Patient
Record: An Essential Technology for Health Care (Washington, D.C.:
National Academy Press, 1997).
[13] DOD is developing an enhanced health information system, CHCS II.
Starting this year, this system will be deployed in installments over
the next 6 years and will allow for capturing additional patient
information and provide more capabilities, for instance, more clinical
decision support, than CHCS currently has.
[14] JCAHO Sentinel Event Alert, Issue 19, May 2001.
[15] By formulary system, we mean not only the list of preferred drugs
but also the associated processes used by organizations to select safe
and efficacious drugs and to monitor and guide their use.
[16] Institute of Medicine, Description and Analysis of the VA National
Formulary (Washington, D.C.: National Academy Press, 2000).
[17] In the National Defense Authorization Act for Fiscal Year 2000,
Congress required DOD to implement a uniform drug formulary by October
2000, applicable to military pharmacies, retail pharmacies, and DOD's
mail order pharmacy (Pub. L. No. 106-65 § 701 (a)(1), (2)(A), 113 Stat.
512, 677 (2000) (codified to 10 U.S.C. 1074g (a)(1), (2)(A) (2000)).
DOD issued a proposed rule to establish a uniform formulary in April
2002, but this rule has not been finalized (67 Fed. Reg. 17948 (2002)).
[18] CPOE allows direct entry of medication orders by a prescriber into
a system that electronically transmits these orders to the pharmacy for
filling.
[19] David W. Bates and others, ’Effect of Computerized Physician Order
Entry and a Team Intervention on Prevention of Serious Medication
Errors,“ The Journal of the American Medical Association, vol. 280, no.
15 (1998), and David W. Bates and others, ’The Impact of Computerized
Physician Order Entry on Medication Error Prevention,“ The Journal of
the American Medical Informatics Association, vol. 6, no. 4 (1999).
[20] DOD is evaluating a new pharmacy package that would include
inpatient ordering capability; however, officials were unable to
provide us with an expected implementation date.
[21] Chemotherapy and total parenteral nutrition are excepted for
inpatient ordering; narcotics, chemotherapy, and clinic-stocked items
(such as immunizations) are excepted for outpatient ordering.
[22] VA officials told us that about 14 percent of VA patients have
prescriptions filled at more than one VA facility. Although VA
providers have the ability to remotely view patients‘ records in other
facilities, this systemwide information is not included in automatic
drug checks.
[23] Although DOD lacks computerized provider order entry for
inpatients at most locations, this automatic check occurs when
inpatient medication orders are entered into CHCS by pharmacy staff.
[24] Such services are often provided by pharmacy benefits managers,
organizations that manage the prescription drug benefit on behalf of
the benefit sponsor, which may be a health plan, a health maintenance
organization, a union, or an employer.
[25] Mark Monane and others, ’Improving Prescribing Patterns for the
Elderly Through an Online Drug Utilization Review Intervention: a
system linking the physician, pharmacist, and computer,“ The Journal of
the American Medical Association, vol. 280, no. 14 (1998), p. 1249(1).
[26] Neither agency has an inpatient facility at Key West.
[27] Homeless veterans in Key West obtain all their medications through
the DOD pharmacy.
[28] While physicians have initial responsibility for making drug
decisions, pharmacists also play a role in ensuring the safety of
medication orders.
[29] Dual eligibles face a similar situation when they use VA providers
but have their prescriptions filled by DOD or vice-versa.
[30] In a demonstration of CHCS and CPRS, we observed that CPRS was
more user-friendly. Navigating the system was easier because, unlike
CHCS, which requires most commands to be typed in, most CPRS commands
are selected with a mouse.
[31] President‘s Task Force To Improve Health Care Delivery For Our
Nation‘s Veterans Interim Report, July 2002.
[32] The mission of FHIE, formerly known as the Government Computer-
Based Patient Record (GCPR) project, is to enable the electronic
exchange of selected health information between VA and DOD. Begun in
1998, GCPR was intended to provide for the sharing of clinical patient
data among VA, DOD, and the Indian Health Service (IHS). Initial plans
for GCPR called for deployment in October 2000, but, as we reported in
2001, the project suffered from expanding time frames and cost
estimates and was refocused. For further details see U.S. General
Accounting Office, Computer-Based Patient Records: Better Planning and
Oversight by VA, DOD, and IHS Would Enhance Health Data Sharing,
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-01-459] (Washington,
D.C.: Apr. 30, 2001).
[33] VA filled 100 million prescriptions and treated 3.8 million unique
patients in fiscal year 2001 for an average of 26 prescriptions per
person for the year.
[End of section]
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