The Veterans Affairs Pharmacy System: Perfectly Designed to Achieve the Outcomes It Gets

On the surface, the study by Thorpe and colleagues (1) seems to be only about medication prescribing for dementia in the Veterans Affairs (VA) system, but it could serve as the basis for an entire medical school course on health policy. It has far-reaching implications for health care system design, medication prescribing, and daily clinical practice, particularly for the care of patients with chronic disease. The study highlights an overarching concept: Every system is perfectly designed to achieve the outcomes it gets. Health policy decisions in the United States give priority to consumer choice, especially as it relates to expanded access to care (2). The assumption is that more convenient access coupled with choice will be best for patients. But Thorpe and colleagues show that expanding access and choice can have a significant downside, particularly when the health care system increases choice without also focusing on care coordination and information exchange between providers. The researchers followed veterans with dementia who received their medications only within the VA system (VA-only users) and those who also received medications outside the VA system through Medicare Part D (dual users) (1). They found that dual users had more than double the odds of exposure to medications that increase a person's risk for adverse events. On average, dual users received these potentially harmful medications for 1.5 months longer than VA-only users. This finding should come as no surprise. After all, Every system is perfectly designed to achieve the outcomes it gets. Without the design of a system to share information on medication use and prescribing to the various providers caring for veterans, the current system relies on individual clinicians' due diligence to reconcile medications and evaluate the potential for drugdrug interactions. Unsurprisingly, this system is associated with poor prescribing and medication-related adverse events. Another unfortunate example is opioid prescribing in the United States, which has only recently led many states to establish opioid registries (3). However, many of our patients have several chronic conditions that require various medications. Better coordination of all of their medications, not just opioids, is needed. The adage of we can put a man on the moon but we can't comes to mind. I can access my bank accounts from almost any bank and obtain cash almost anywhere in the world. When my credit card seems to have been used by someone else, the account is instantly shut down. One would think that sharing of medication information between pharmacies and physicians and protecting patients from potentially unsafe medications should be just as easy. The Industrial Revolution in this country was characterized by the standardization of parts to enable assembly line production and the ability to easily fix broken cars and other products with interoperable parts. However, we have been resistant to analogous interoperability in medicine. In fact, although the government has promoted interoperability with billions of dollars in financial incentives, providers who use the same electronic health record at different institutions often cannot access each other's records for shared patients (4). Standardized transmission of laboratory data, which was identified as a priority in 1999, is still evolving (5). Pharmacies were able to agree on standard protocols to classify, transmit, and share prescription information (6), but this has not translated into the sharing of medication data in health information exchanges accessible by all clinicians. Although interoperability is difficult to create, much of it would not be necessary if we did not let choice of information systems, electronic health records, and other clinical tools trump standardization. Thorpe and colleagues note that the VA system has a robust integrated pharmacy and medical record system available in all of the VA health care settingsa system clearly built to achieve better outcomes. Yet when using 3 indicators of unsafe medications among veterans with dementia, the researchers found that approximately 4 of every 10 VA-only users still received potentially harmful medications (1). Anticholinergic medications were the most commonly prescribed drugs but have long been known to be potentially harmful for elderly persons (7). The Office of Inspector General of the U.S. Department of Health and Human Services has shown that the leading cause of adverse events in hospitals and skilled-nursing facilities is related to medications, many of which induce delirium due to their anticholinergic properties (8). Yet we as a profession continue to prescribe these medications for our elderly patients. Again, the prioritization of choice holds us back from building a better system. Clinical decision-support systems have been shown to help improve medication prescribing and laboratory ordering (9, 10). However, much work remains to optimize these systems and have clinicians become more comfortable using them (9, 10). The results of the current study underscore this point. Patients who use only the VA system, which has both integrated pharmacy information and clinical decision-support systems, have better outcomes than those using other systems but still fall short of achieving the results we want. Throughout my career, I have said, That's the system, or I often hear this from other physicians when we discuss something that went wrong for one of our patients. At best, the health care system (whether it be at the national, regional, or local level or within a clinic or hospital unit) is often preventing our patients from achieving the outcomes they deserve. At worst, this system is harming them. The system is having more of an effect on our patients' outcomes than what we can accomplish by delivering the best bedside care. We need to more actively address how the policy about the choice of access, information systems, and clinical decision making is creating systems that harm our patients. This study underscores the need for us to advocate for greater interoperability of information and use of clinical decision-support systems in all systemsnot just in the VA system.