VA INFORMATION 

TECHNOLOGY

Pharmacy System 

Needs Additional 

Capabilities for 

Viewing, Exchanging, 

and Using Data to 

Better Serve Veterans

Report to Congressional Committees

June 2017

GAO-17-179

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-17-179, a report to 

congressional committees

June 2017

VA INFORMATION TECHNOLOGY 

Pharmacy System Needs Additional Capabilities for 

Viewing, Exchanging, and Using Data to Better Serve 

Veterans

What GAO Found

The Department of Veterans Affairs (VA) has system capabilities through 

multiple computer applications that support its clinicians and pharmacists in 

prescribing and dispensing medications to patients. However, pharmacists 

cannot always efficiently view necessary patient data among Veterans Health 

Administration (VHA) medical sites. In addition, pharmacists cannot transfer 

prescriptions to other VHA pharmacies or process prescription refills received 

from other VHA medical sites through the system. As a result, the system does 

not provide important capabilities for pharmacists to make clinical decisions 

about prescriptions efficiently, which could negatively affect patient safety.

In its efforts to establish and increase interoperability with the Department of 

Defense (DOD), VA has developed capabilities to exchange certain patient and 

medication information. For example, VA’s pharmacy system has the ability to 

check prescription drug information from DOD. Nevertheless, limitations impede

interoperability with DOD: (1) VA clinicians and pharmacists cannot always view 

DOD patient data and (2) VA pharmacists do not always receive complete 

information from DOD to perform prescription checks on new medications. Also, 

VA has not assessed the impact of its pharmacy system interoperability on 

service members transitioning from DOD to VA, and VHA officials stated that 

doing so would be difficult because there are other personnel related-factors that 

could affect patient-care outcomes. Without assessing the impact that pharmacy 

system interoperability is having on veterans, VA lacks assurance regarding the

effectiveness of the system to adequately support its mission of providing health

care to veterans.

VA’s pharmacy system capabilities align with three of six identified health care 

industry practices. Specifically, the pharmacy system (1) provides the ability to 

order medications electronically, (2) enables prescription checks for drug-to-drug 

and drug-allergy interactions, and (3) tracks the dispensing of controlled 

prescription drugs. However, the pharmacy system lacks capabilities that align 

with three other practices which could enhance its usefulness:

• Pharmacists cannot electronically exchange prescriptions with non-VA

providers and pharmacies. Therefore, veterans need to obtain paper 

prescriptions from external providers or have the providers fax the 

prescriptions to their local VA pharmacy to fill the prescriptions, which is time 

consuming and inefficient.

• VA’s system does not include certain clinical decision and workflow 

capabilities that, among other things, could improve clinicians’ and 

pharmacists’ ability to provide enhanced medical care to veterans. VA has 

indicated that it plans to implement such capabilities, but its plans for doing 

so are incomplete.

• VA’s system does not maintain a perpetual inventory management capability

to monitor medication inventory levels. Therefore, pharmacists cannot 

effectively track when to reorder medications.

In the absence of these capabilities, VA is limited in its ability to interoperate with 

private providers, provide additional clinical decision support, and more 

effectively track medications that could impact veterans’ patient safety.

View GAO-17-179. For more information, 

contact Valerie Melvin at (202) 512-6304 or 

melvinv@gao.gov.

Why GAO Did This Study

VHA provides health care services, 

including pharmacy services, to 

approximately 6.7 million veterans and 

their families. To do so, clinicians and 

pharmacists rely on VA’s health 

information system. The National 

Defense Authorization Act for Fiscal 

Year 2003 required VA to ensure it has 

a pharmacy system that is 

interoperable with DOD’s system.

A provision in Senate Report 114-57 

required GAO to examine VA’s 

acquisition and use of a pharmacy 

system. GAO determined whether (1)

VA currently possesses a functioning 

pharmacy system and the extent to 

which the system enables data to be 

viewed, shared, and transferred among 

VHA pharmacy locations; (2) VA’s 

pharmacy system is interoperable with 

DOD’s, and whether this system, or the 

absence thereof, is impacting service 

members who transition care from 

DOD; and (3) VA has implemented its 

pharmacy system in accordance with

health care industry practices. GAO 

analyzed documentation describing 

VA’s pharmacy system; observed 

system demonstrations; analyzed 

plans and actions taken to achieve 

interoperability with DOD; and

identified industry practices related to 

pharmacy systems, and compared 

them to VA’s system capabilities.

What GAO Recommends

GAO is making six recommendations

including that VA update its pharmacy 

system to view and receive complete 

medication data, assess the impact of 

interoperability, and implement 

additional industry practices. VA 

generally concurred with GAO’s six 

recommendations.
Page i GAO-17-179 VA Pharmacy IT

Letter 1

Background 6

VA Has Pharmacy System Capabilities, but Inefficiencies Exist in 

Viewing and Transferring Data 16

VA’s Pharmacy System Has Certain Interoperability Capabilities 

with DOD, but Limitations Reduce Effectiveness; VA Has Not 

Assessed the Impact of Interoperability 23

VA’s Pharmacy System Incorporates Some Health Care Industry 

Practices, but Not Others 28

Conclusions 35

Recommendations for Executive Action 36

Agency Comments and Our Evaluation 37

Appendix I Objectives, Scope, and Methodology 39

Appendix II Department of Veterans Affairs Pharmacy Related Applications 45

Appendix III Department of Veterans Affairs and Department of Defense 

Interoperability Initiatives 47

Appendix IV Comments from the Department of Veterans Affairs 48

Appendix V GAO Contact and Staff Acknowledgments 54

Tables

Table 1: Veterans Health Information Systems and Technology 

Architecture (VistA) Applications Used for Pharmacy 45

Table 2: Department of Veterans Affairs (VA) and Department of 

Defense (DOD) Sharing Initiatives for Pharmacy Data 47

Contents
Page ii GAO-17-179 VA Pharmacy IT

Figures

Figure 1: Simplified Overview of the Department of Veterans 

Affairs’ Outpatient Prescription Process 7

Figure 2: Timeline of the Department of Veterans Affairs’ 

Pharmacy Application Modernization Initiatives 10

Figure 3: Simplified Depiction of the Department of Veterans 

Affairs’ Applications and Viewers for Prescribing and 

Dispensing Outpatient Medications 19

Abbreviations

AHLTA Armed Forces Health Longitudinal Technology 

 Application

CPRS Computerized Patient Record System

DOD Department of Defense

HHS Department of Health and Human Services

IT information technology

VA Department of Veterans Affairs

VHA Veterans Health Administration

VistA Veterans Health Information Systems and 

 Technology Architecture

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Page 1 GAO-17-179 VA Pharmacy IT

441 G St. N.W.

Washington, DC 20548

June 14, 2017

The Honorable Jerry Moran

Chairman

The Honorable Brian Schatz

Ranking Member

Subcommittee on Military Construction, Veterans Affairs, and 

 Related Agencies

Committee on Appropriations

United States Senate

The Honorable Charlie Dent

Chairman

The Honorable Debbie Wasserman Schultz

Ranking Member

Subcommittee on Military Construction, Veterans Affairs, and 

 Related Agencies

Committee on Appropriations

House of Representatives

Within the Department of Veterans Affairs (VA), the Veterans Health 

Administration (VHA) operates one of the nation’s largest health care 

systems. As a significant part of delivering health care to veterans, VHA 

provides medications, prescription refills, and other pharmacy services. In 

addition to patient data from its own system, to help ensure that it has 

access to the necessary health information that could assist clinicians 1

and pharmacists in making informed decisions about the health of 

veterans, VA relies on patient data from the Department of Defense 

(DOD). The two departments have been working since 1998 to 

electronically exchange patient data across their electronic health 

information systems. Yet, we have previously noted that VA has faced 

significant information technology (IT) challenges that have contributed to 

 1A clinician is a doctor or other provider who is authorized to provide patient care. VA 

clinicians may include pharmacists, physicians, physician assistants, nurse practitioners, 

dentists, or practitioners from other disciplines. In this report, we refer to pharmacists in 

their role of dispensing medication and refer to pharmacists performing direct patient care 

and prescribing roles as clinicians.

Letter
Page 2 GAO-17-179 VA Pharmacy IT

our designation of VA health care as a high-risk area for the federal 

government.2

The Bob Stump National Defense Authorization Act for Fiscal Year 2003 

required VA to ensure it has a pharmacy system that is interoperable with 

DOD’s system.3 Specifically, the act required that the departments’

systems achieve real-time interface, data exchange, and the ability to 

check prescription drug information for outpatients. The act also required 

that the systems use national standards for exchanging outpatient 

medication information.

The Senate Appropriations Committee Report 114-57 accompanying the 

Consolidated Appropriations Act, 2016 called for us to examine VA’s 

acquisition and use of a pharmacy data system.4 The specific objectives 

of our review were to determine whether (1) VA currently possesses a 

functioning pharmacy system and the extent to which the system enables 

data to be viewed, shared, and transferred among VHA pharmacy 

locations; (2) VA’s pharmacy system is interoperable with DOD’s and, 

whether this system, or the absence thereof, is impacting service 

members who transition care from DOD; and (3) VA has implemented its 

pharmacy system in accordance with health care industry practices.

To address the first objective, we obtained and analyzed documentation 

describing VA’s pharmacy system, such as technical manuals and 

architecture diagrams that showed the current and planned capabilities of 

the system. In addition, we observed demonstrations of the system at VA 

medical centers in Baltimore, Maryland; Butler, Pennsylvania; and San 

Antonio, Texas. We also visited a joint VA and DOD health center in 

North Chicago, Illinois to review capabilities for viewing, sharing, and 

transferring pharmacy data between VHA locations. Our criteria for 

 2GAO, High Risk Series: An Update, GAO-15-290 (Washington, D.C.: Feb. 11, 2015).

3Pub. L. No. 107-314, § 724, 116 Stat. 2458, 2598 (2002). In 2005, GAO found that 

completion of VA’s pharmacy prototype satisfied the sec. 724 mandate. GAO, ComputerBased Patient Records: VA and DOD Made Progress, but Much Work Remains to Fully 

Share Medical Information, GAO-05-1051T (Washington, D.C.: Sept. 28, 2005).

4S. Rep. No.114-57 at 61-62 (2015). The Senate committee requested us to review 

whether VA currently possesses a functioning pharmacy data transaction system. The 

committee references the Bob Stump National Defense Authorization Act for Fiscal Year 

2003, which referred to VA’s pharmacy data system. We use the term pharmacy system in 

our report to avoid confusion with a DOD system named the Pharmacy Data Transaction 

Service.
Page 3 GAO-17-179 VA Pharmacy IT

selecting these sites was intended to ensure coverage of (1) different 

geographic locations, (2) the various types of VA facilities (e.g., a medical 

center and an independent outpatient clinic), and (3) a location piloting 

the new VA enterprise health platform. Our selection criteria also ensured 

that we included sites of varying sizes, and which offered a breadth of 

medical services.

To address the second objective, we reviewed VA technical manuals and 

architecture diagrams, and documents produced by the VA/DOD 

Interagency Program Office.5 We analyzed the department’s plans and 

identified its actions taken toward achieving interoperability with DOD. We 

then compared the department’s actions to relevant requirements 

specified in the fiscal year 2003,6 2008,7 and 20148 National Defense 

Authorization Acts. We observed clinicians’ and pharmacists’ use of VA 

and DOD systems for the purposes of exchanging pharmacy data in realtime and performing prescription drug data checking for outpatients.

Additionally, we reviewed VA documentation to learn how the department 

was monitoring and checking prescription drug data exchanged with 

DOD. We also obtained written responses from VA on questions 

regarding interoperability and reviewed VA reports and documents, 

including a report to Congress on interoperability standards, to evaluate 

the extent the pharmacy system conformed to national standards for the 

exchange of outpatient medication information between VA and DOD.

Further, to address the third objective, we conducted literature searches, 

reviewed our prior work, and consulted with various sources to identify 

industry practices associated with pharmacy IT systems. These sources 

included our previous reports, the Department of Health and Human 

 5The VA/DOD Interagency Program Office was put in place to be accountable for VA’s 

and DOD’s efforts to achieve interoperability.

6Pub. L. No. 107-314, § 724, 116 Stat. 2458, 2598 (2002).

7Pub. L. No. 110-181, § 1635, 122 Stat. 3, 460-463 (2008).

8Pub. L. No. 113-66, § 713, 127 Stat. 672, 794-798 (2013).
Page 4 GAO-17-179 VA Pharmacy IT

Services’ Office of the National Coordinator for Health Information 

Technology,9 the American Society of Health-System Pharmacists,10 the 

Archives of Pharmacy Practice,11 and a private provider.12 We reviewed 

the Office of the National Coordinator for Health Information Technology’s 

certification criteria for health IT systems 13 and its advisory on 

interoperability standards.14 We also reviewed Gartner’s Update to the 

Enterprise Electronic Health Record Generation Model,15 as well as 

standards set by the National Council for Prescription Drug Programs.16

From these sources, we compiled a list of practices that the health care 

industry has identified as being relevant to the implementation of an 

effective pharmacy IT system and that reflect areas of relevance with 

regard to VA’s health information system capabilities. This resulted in a 

 9The Office of the National Coordinator for Health Information Technology is responsible 

for overseeing the certification of electronic health record technology, including 

establishing technical standards and corresponding certification criteria. Additionally, the 

Office of the National Coordinator for Health Information Technology is charged with 

formulating the federal government’s health IT strategy and coordinating related policies, 

programs, and investments.

10American Society of Health-System Pharmacists, Policy Positions, 2009-2015 (with 

Rationales): Automation and IT.

11A. K. Ali, “Inventory Management in Pharmacy Practice: A Review of Literature” 

Archives of Pharmacy Practice. Vol. 2 Issue 4 (2011).

12Kaiser Permanente Medical Care Program is an integrated health care delivery system 

that jointly works with VA to provide care to veterans. Kaiser Permanente was part of a 

pilot program in 2009 connecting Kaiser’s and VA’s electronic health record systems.

1380 Fed. Reg. 62602 (Oct. 16, 2015). Department of Health and Human Services, 2015 

Edition Health Information Technology (Health IT) Certification Criteria, 2015 Edition Base 

Electronic Health Record Definition and the Office of the National Coordinator for Health 

Information Technology Health IT Certification Program Modifications Final Rule.

14Office of the National Coordinator for Health IT, 2016 Interoperability Standards 

Advisory (January 2016).

15Gartner, Gartner’s Update to the Enterprise Electronic Health Record Generation Model, 

(August 2016); Gartner uses a generation model to track the progression in capabilities of 

electronic health record systems evolving from very simple systems that provide results 

reporting tools to complex, fully integrated systems that clinicians can use to help facilitate 

the practice of evidence-based medicine. Gartner first introduced a five-stage enterprise 

electronic health record generation model in 1998, updated the model in 2007 and more 

recently in 2016.

16The National Council for Prescription Drug Programs’ Script standard version 10.6 

specifies the standard for providers to use when sending a prescription electronically to a 

pharmacy.
Page 5 GAO-17-179 VA Pharmacy IT

list of six practices that relate to (1) ordering medication electronically, (2) 

receiving drug order checks, (3) tracking the dispensing of controlled 

prescription drugs, (4) electronically exchanging prescriptions, (5) using 

clinical decision support capabilities, and (6) using a perpetual inventory 

management capability to monitor medication inventory levels.

We confirmed the validity and relevance of the identified practices with 

the Office of the National Coordinator for Health Information Technology. 

We also confirmed our selection of the practices through discussions with 

industry leaders. Based on the views and experiences of these sources, 

we characterized the practices discussed in our report as being industry 

practices (rather than best practices).

We also reviewed various VA documentation, including its pharmacy 

system architecture and user manuals, a VA Office of Inspector General 

report on pharmacy re-engineering,17 a 2011 comparison of VA’s 

electronic health record system to leading commercial solutions,18 and 

VA’s plans to implement pharmacy system capabilities through its 

pharmacy re-engineering project. We then used this information to assess 

VA’s current system capabilities and modernization plans against the 

identified industry practices to identify gaps.

We supplemented our analyses with interviews of VA, DOD, and 

Department of Health and Human Services officials with knowledge of 

VA’s pharmacy system and the interoperability efforts within the 

department and with DOD. These officials included those in VA’s Office of 

Information and Technology and in VHA, including the Pharmacy Benefits 

Management Services, as well as those with the VA National Center for 

Patient Safety. We also interviewed officials in the Department of Health 

and Human Services’ Office of the National Coordinator for Health 

Information Technology as well as DOD officials in the Defense Health 

Agency and DOD/VA Program Coordination Office. Additional details on 

our objectives, scope, and methodology are discussed in appendix I.

 17Department of Veterans Affairs Office of Inspector General, Audit of the Pharmacy 

Reengineering Software Development Project (12-04536-308), (Dec. 23, 2013).

18Department of Veterans Affairs, Health Information Strategic Plan for Veterans Health 

Administration Supporting VA Health Care Fiscal Year 2014-2019, Version 2.4 (July 2014) 

and Gartner Consulting, VistA Comparison to the Commercial Electronic Health Record 

Marketplace Final Report, (Feb. 4, 2011).
Page 6 GAO-17-179 VA Pharmacy IT

We conducted this performance audit from January 2016 to June 2017 in 

accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that 

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives.

VHA provides health care to approximately 6.7 million veterans and their 

families at an estimated annual cost of about $56 billion.19 In 2016, the 

agency reported that it employed approximately 207,000 clinical staff to 

care for veterans in numerous venues throughout the United States and 

its territories.20 These venues include 168 VA medical centers and 

approximately 750 primary care and multi-specialty outpatient clinics.

Within VHA, Pharmacy Benefits Management Services is responsible for 

providing a broad range of pharmacy services, such as promoting 

appropriate drug therapy, ensuring medication safety, providing clinical 

guidance to pharmacists and other clinicians, and maintaining VA drugs 

and supplies used to deliver pharmacy benefits, among other services. To 

provide these services, VHA operates about 260 pharmacies located in 

the medical centers and outpatient clinics, as well as 7 consolidated mail 

outpatient pharmacies.21 Veterans can receive treatment and obtain and 

fill prescriptions at the medical centers and outpatient clinics; they can 

also receive medications by mail via the consolidated mail outpatient 

pharmacies.

According to the department, outpatient prescribing is performed most 

predominantly. For fiscal year 2016, VHA reported that it provided 

outpatient pharmacy services to approximately 5 million veterans. The 

agency further reported that about 31 million outpatient prescriptions were 

 19Active duty service members may also receive certain health care services from VA 

through referrals from DOD or sharing agreements.

20At the end of fiscal year 2016, VHA had an average onboard total of 207,406 clinical 

employees in 34 types of occupations covered by 38 U.S.C § 7401 that governs VHA 

appointments and authorizes the Secretary to appoint specified clinicians.

21As one means of delivering medications to patients, VHA uses a mail delivery service 

made up of seven consolidated mail outpatient pharmacy facilities. These facilities are 

located in Leavenworth, Kansas; Tucson, Arizona; Chelmsford, Massachusetts; Dallas, 

Texas; Murfreesboro (Nashville), Tennessee; Hines (Chicago), Illinois; and Charleston, 

South Carolina.

Background
Page 7 GAO-17-179 VA Pharmacy IT

filled at medical center and outpatient clinic pharmacies, and about 116 

million prescriptions were filled by consolidated mail outpatient 

pharmacies. VHA estimated that it spent approximately $6.3 billion for 

pharmacy services in fiscal year 2016 and it has requested about $7.7 

billion for pharmacy services in fiscal year 2017.

In prescribing medication for an outpatient, clinicians generally follow a 

prescription process in which the clinician first reviews the patient’s 

medical record and selects an appropriate medication from VA’s 

approved list of medications. The clinician then orders the necessary 

medication. For each order, the clinician performs checks to identify any 

excessive dosage, or any possible interactions for the medication; for 

example, the patient may be allergic to that medication. Medication orders 

are then reviewed by a pharmacist, who dispenses the drug and updates 

the patient’s medical record to reflect the medication that was dispensed. 

The general process for prescribing and dispensing prescription 

medications to VA patients is depicted in figure 1.

Figure 1: Simplified Overview of the Department of Veterans Affairs’ Outpatient Prescription Process
Page 8 GAO-17-179 VA Pharmacy IT

VHA relies on the department’s health information system—the Veterans 

Health Information Systems and Technology Architecture (VistA)—to 

deliver health care.22 VistA consists of approximately 200 separate 

computer applications and modules that provide health care delivery 

capabilities. This includes multiple computer applications which have 

pharmacy capabilities.

A key application within VistA—the Computerized Patient Record System 

(CPRS)—enables the department to create and update an individual 

electronic health record for each VA patient.23 Specifically, CPRS enables 

clinicians to enter, review, and continuously update information connected 

with a patient. Among other things, clinicians can order lab tests, 

medications, diets, radiology tests, and procedures; record a patient’s 

allergies or adverse reactions to medications; request and track consults; 

enter progress notes, diagnoses, and treatments for each encounter; and 

enter discharge summaries. Over the last three decades, local VHA 

medical sites have made numerous modifications to VistA, resulting in 

about 130 different instances, or variations, of the system.

Since 2001, VA has recognized the need to modernize VistA and several 

of its efforts also were aimed at improving the department’s pharmacy 

capabilities. Specifically, in that year, VHA began the HealtheVet initiative 

to standardize patient data and modernize health information software 

applications. Under HealtheVet, VA began the Pharmacy Re-engineering 

project in 2002, with the intent of replacing all of the legacy applications 

that supported pharmacy services in order to meet current and future 

patient needs. The department had initially planned the Pharmacy Reengineering project to be completed for deployment in 2009.

However, in June 2009, the Secretary of Veterans Affairs announced that 

VA would stop financing failed projects and improve the management of 

its IT development projects. Toward this end, the VA Chief Information 

Officer transitioned the Pharmacy Re-engineering project to a phased 

development effort. According to VA pharmacy management officials, this 

 

22VistA began operation in 1983 as the Decentralized Hospital Computer Program. In 

1996, the name of the system was changed to the Veterans Health Information Systems 

and Technology Architecture. 

23An electronic health record is a collection of information about the health of an individual 

or the care provided, such as patient demographics, progress notes, health problems, 

medications, vital signs, past medical history, immunizations, laboratory data, and 

radiology reports.

Veterans Health 

Information Systems and 

Technology Architecture

and Its Pharmacy 

Applications
Page 9 GAO-17-179 VA Pharmacy IT

was done because the project had faced funding delays, contracting 

difficulties, and differing directions from a number of VA chief information 

officers. The project was also rescoped to focus on implementing clinical 

decision support tools, specifically to cross-check drugs in medication 

orders to reduce the frequency of adverse drug events and improve 

patient safety.24

In August 2010, VA reported that it had terminated the HealtheVet 

initiative. Subsequently, from March 2011 to February 2013, VA worked

toward the development of a new, joint integrated electronic health record 

system with DOD.25 In October 2011, pharmacy requirements were 

developed as a part of the joint integrated electronic health record 

initiative. However, the joint integrated electronic health record system 

was discontinued in February 2013 based on concerns about the program 

facing challenges in meeting deadlines, costing too much, and taking too 

long to deliver capabilities.

In December 2013, VA began a new program, VistA Evolution, to 

enhance and modernize the existing health information system (VistA) by 

incrementally deploying capabilities through fiscal year 2018. This 

initiative included plans for future pharmacy enhancements, such as 

additional order checks 26 and automatic updates to replace the slow (60-

day) manual inclusion of new drugs into the medication ordering and 

management process, as part of the Pharmacy Re-engineering project. 

The planned pharmacy enhancements also included inbound eprescribing, a capability to receive inbound electronic prescriptions (eprescriptions) from a non-VA provider, and then fill, and dispense the 

 24These tools include the Medication Order Check Healthcare Application, Pharmacy 

Enterprise Customization System, and Pharmacy Product System. The Pharmacy Reengineering project is also focused on standardizing and transitioning the National Drug 

File to the Pharmacy Product System to support medication ordering and dispensing.

25To accelerate the exchange of electronic health information between DOD and VA, the 

National Defense Authorization Act for Fiscal Year 2008 included provisions directing VA 

and DOD to jointly develop and implement fully interoperable electronic health records or 

capabilities.

26Additional checks include, for example, checks for possible negative drug effects on 

kidney and liver functions.
Page 10 GAO-17-179 VA Pharmacy IT

prescriptions in VistA. From fiscal years 2002 to 2016, VA reported 

spending about $187.6 million for the Pharmacy Re-engineering project.27

Figure 2 shows a timeline of the modernization initiatives for the 

Pharmacy Re-engineering project in relation to VA’s VistA modernization 

initiatives.

Figure 2: Timeline of the Department of Veterans Affairs’ Pharmacy Application Modernization Initiatives

VA’s Office of Information and Technology has responsibility for providing 

technology services across the department, including the development 

and management of all IT assets and resources. As such, the office is to 

support VHA in planning for and acquiring IT capabilities that meet 

business requirements, to include delivering the necessary technology 

and expertise that support health care providers within VA’s network of 

hospitals, outpatient facilities, and pharmacies. Specifically, regarding 

 27For fiscal years 2002 through 2013, VA reported to the Office of Management and 

Budget spending about $152.9 million for Pharmacy Re-engineering. In 2014, the 

Veterans Access, Choice, and Accountability Act was enacted and according to officials, 

VA has used these funds for the Pharmacy Re-Engineering project. Therefore, for fiscal 

years 2014 through 2016, VA reported obligations of about $34.7 million.
Page 11 GAO-17-179 VA Pharmacy IT

pharmacy services, it has responsibility for developing computer systems 

based on requirements from Pharmacy Benefits Management Services.

To support its efforts to deliver health care, DOD uses the Armed Forces 

Health Longitudinal Technology Application (AHLTA)—its outpatient 

electronic health information system. AHLTA is used to generate, 

maintain, store, and access patient electronic health records; and it is 

comprised of multiple legacy medical information systems that were 

developed from commercial software products and customized for 

specific uses. For example, the Composite Health Care System, which 

was formerly DOD’s primary health information system and serves as a 

foundation for AHLTA, is used to capture information related to pharmacy, 

radiology, and laboratory order management. The Composite Health Care 

System also allows clinicians to electronically prescribe medications.

DOD relies on its system, called the Pharmacy Data Transaction Service, 

for its pharmacy capabilities. This system is a central repository for 

prescription data from all DOD pharmacies. Further, it detects duplicate 

drug treatments, therapeutic overlap, and drug interactions. It also 

contains data on specific drugs, dosages, and dispensing dates. The 

repository includes data for DOD prescriptions processed through 

authorized private and DOD medical facilities’ pharmacies, as well as 

through the mail.

The department is currently in the process of transitioning from its existing 

electronic health record systems to a new commercial electronic health 

record system called MHS GENESIS. The transition to the new system 

began in February 2017 in the Pacific Northwest region of the United 

States.28 According to the department, the new system is to integrate 

inpatient and outpatient solutions and provide medical and dental 

information. AHLTA and the Composite Health Care System are among 

the systems that are intended to be replaced by the new system.

According to the Department of Health and Human Services’ Office of the 

National Coordinator for Health Information Technology, the American 

Society of Health-System Pharmacists, and others, industry practices for 

 28DOD’s initial deployment of the new system is planned to be at a number of sites in 

Washington state, to include the following: Naval Hospital Bremerton, Bremerton; 92nd

Medical Group, Fairchild Air Force Base; Madigan Army Medical Center, Joint Base 

Lewis-McChord; and Naval Hospital Oak Harbor, Oak Harbor.

DOD’s Armed Forces 

Health Longitudinal 

Technology Application 

and Pharmacy System

Pharmacy IT System

Industry Practices
Page 12 GAO-17-179 VA Pharmacy IT

pharmacy IT systems stress the use of capabilities aimed at improving 

the efficiency and effectiveness of clinicians and pharmacists in 

prescribing and dispensing medication.29 Among others, these 

capabilities would enable clinicians and pharmacists to:

• Electronically order medications, and record, change, and access a 

medication order for a patient.30 Computerized order entry improves 

the safety, efficiency, and accuracy of the medication-use process by 

enabling the pharmacist to review and verify the medication order 

before filling it.31

• Perform drug-to-drug interactions and drug-allergy interaction checks 

during computerized order entry. Before a medication order is 

completed and acted upon, interventions should automatically indicate 

to a user drug-to-drug and drug-allergy contraindications based on a 

patient’s medication list and medication allergy list.32 Clinical decision 

support systems, such as drug interaction, allergy, and dose 

 29For example, we identified industry practices based on 80 Fed. Reg. 62640 (Oct. 16, 

2015); Office of the National Coordinator for Health Information Technology, 2016 

Interoperability Standards Advisory (January 2016); the American Society of HealthSystem Pharmacists, Guidelines and Policy Positions, 2009-2015 (with Rationales): 

Automation and IT; K. R Saverno, L. E. Hines, T. L. Warholak, A. J. Grizzle, L. Babits, C. 

Clark, A. M. Taylor, and D. C Malone, “Ability of pharmacy clinical decision-support 

software to alert users about clinically important drug-drug interactions,” Journal of the 

American Medical Informatics Association, Vol. 18 (2011) 32-37; and A. K. Ali, “Inventory 

Management in Pharmacy Practice: A Review of Literature,” Archives of Pharmacy 

Practice. (Vol. 2 Issue 4, 2011).

3080 Fed. Reg. 62747 (Oct. 16, 2015). Through a regulatory process, the Office of the 

National Coordinator for Health Information Technology authorizes certification bodies to 

(on its behalf) certify whether health IT, including electronic health record systems, meet 

certain functional and technical requirements, including conformance to standards and 

implementation specifications. Providers that participate in the Medicare and Medicaid 

Electronic Health Record Incentive Programs must demonstrate that they are “meaningful 

users” of certified health IT. The Office of the National Coordinator for Health Information 

Technology verified that the requirements and criteria in the 2015 Edition Health IT 

Certification Criteria we identified are key practices applicable to pharmacy systems. VA 

indicated that it plans to meet these requirements.

31American Society of Health-System Pharmacists, Policy Positions, 2009-2015 (with 

Rationales): Automation and IT.

3280 Fed. Reg. 62747 (Oct. 16, 2015).
Page 13 GAO-17-179 VA Pharmacy IT

monitoring warning systems, should be adopted to make patient care 

more efficient and effective.33

• Track the dispensing of controlled prescription drugs to patients

through state-run prescription monitoring drug programs,34 which may 

be used to monitor for suspected abuse or diversion, and can give a 

clinician critical information regarding a patient’s pain management 

and controlled substance prescription drug history.35

• Electronically create prescriptions for electronic transmission in 

accordance with National Council for Prescription Drug Programs 

standards.36 According to the Office of the National Coordinator for 

Health Information Technology, 90 percent of pharmacies in the 

United States are enabled to accept electronic prescriptions, and 70 

percent of physicians are electronically prescribing medication.

• Use capabilities that would help guide the implementation of improved 

treatment methodologies.37 Specifically, Gartner’s Generation Model 

for Enterprise Electronic Health Record systems is a framework where 

generation level 338 calls for establishing effective clinical decision 

 33American Society of Health-System Pharmacists, Guidelines on the Design of 

Database, Driven Clinical Decision Support: Strategic Directions for Drug Database and 

Electronic Health Records Vendors. American Journal of Health-System Pharmacy 

(2015).

34In March 2014, VA promulgated regulations concerning the sharing of certain patient 

information to implement VA’s authority to participate in state prescription drug monitoring 

programs. 79 Fed. Reg. 14400 (March 14, 2014).

35Department of Health and Human Services, Prescription Drug Monitoring Program 

Interoperability Standards, A Report to Congress (September 2013). 

3680 Fed. Reg. 62640, 62750 (Oct. 16, 2015), and Office of the National Coordinator for 

Health Information Technology, 2016 Interoperability Standards Advisory (January 2016).

37Gartner, Update to the Enterprise Electronic Health Record Generation Model, figure 2 

(August 2016).

38Generation level 3 electronic health record systems are complex systems designed to 

allow clinicians more direct interaction and help facilitate the practice of evidence-based 

medicine. Electronic health record systems at this level must provide functionality for 

ambulatory and all acute care settings, and have effective clinical decision support, 

workflow capacity for care plans, and clinical documentation and display, as well as 

computer-based physician order entry.
Page 14 GAO-17-179 VA Pharmacy IT

support capabilities,39 clinical workflow,40 clinical display,41 as well as 

computer-based physician order entry. According to Gartner, in more 

robust electronic health record products, medication order entry is 

tightly connected to clinical decision support. Generation level 3 

facilitates dissemination of the latest evidence-based practices by 

alerting, reminding, and proactively escalating issues to the clinician 

as necessary.

• Use a computerized system to manage perpetual inventory so the 

system displays up-to-date pharmaceutical inventory at all times. The 

pharmaceutical inventory on hand is entered into the system, and the 

appropriate amount of products is automatically reduced from the 

inventory when a prescription or medication order is filled.42

We have previously reported on VA’s efforts to share pharmacy data. For 

example, in 2007, we reported that the department and DOD were 

exchanging computable outpatient pharmacy data for some shared 

patients,43 but had not completed important steps for exchanging these 

data for all shared patients.44 VA and DOD had developed an electronic 

interface—the Clinical Data Repository/Health Data Repository—that 

linked the two departments’ health data repositories and allowed for the 

exchange of computable data between them. However, we noted that 

shared patients were not activated when patients’ identifying information 

did not match exactly and VA patients who were discharged from active 

 39Clinical decision support helps clinicians make complex decisions and can trigger 

appropriate early notification of possible untoward events.

40Automation systems must provide support for the processes involved in clinical care, as 

well as the information needed. Electronic health record (clinical) workflow capabilities 

enable the health delivery organization to define key processes in such a manner that the 

electronic health record can then assist humans and automated systems in reliably 

carrying out these processes.

41Once captured, data must be presented in a meaningful manner that contributes to the 

clinician's ability to use the data effectively.

42A. K. Ali, “Inventory Management in Pharmacy Practice: A Review of Literature” 

Archives of Pharmacy Practice. Vol. 2 Issue 4 (2011).

43Before computable data can be exchanged, patients in both VA and DOD’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.

44GAO-07-554R.

GAO and VA’s Inspector 

General Have Previously 

Reported on VA’s 

Pharmacy System Efforts
Page 15 GAO-17-179 VA Pharmacy IT

duty before 1997 could not be activated if they did not have a unique 

DOD identification number. In addition, VA and DOD had not established 

written guidelines for defining and identifying shared patients and VA was 

exchanging computable outpatient pharmacy data at a limited number of 

sites.

To help ensure that all shared patients would benefit from the exchange 

of computable outpatient pharmacy data, we recommended that both VA 

and DOD expedite the development of a solution for activating shared 

patients when patients’ identifying information does not match exactly and 

DOD expedite efforts to assign a unique DOD identification number to VA 

patients who were discharged from active duty before 1997. We also 

recommended development of written guidelines for all VA and DOD sites 

to use for defining and identifying shared patients. In addition, we 

recommended that VA expedite efforts to expand to all VA sites the 

capability to automatically check DOD data that are exchanged through 

the Clinical Data Repository/Health Data Repository. Both departments 

concurred with these recommendations and have taken actions to 

implement them.

In addition, the VA Inspector General reported on the department’s 

pharmacy system efforts in 2013.45 The report noted that the Office of 

Information and Technology had not been effective in keeping the 

Pharmacy Re-engineering project on target in terms of schedule and cost, 

as well as the functionality delivered. It noted that project managers had 

struggled to deploy the Pharmacy Re-engineering project increments in a 

timely manner and recommended that VA ensure that each remaining 

Pharmacy Re-engineering increment be reported and monitored; ensure 

adequate oversight and controls, including the planning guidance, 

staffing, and cost and schedule tracking needed to deliver functionality on 

time and within budget; and establish a plan for future funding of the 

Pharmacy Re-engineering project. VA’s Chief Information Officer agreed 

with the Inspector General’s recommendations.

 45Department of Veterans Affairs Office of Inspector General, Audit of the Pharmacy 

Reengineering Software Development Project(12-04536-308), (Dec. 23, 2013).
Page 16 GAO-17-179 VA Pharmacy IT

VA currently has system capabilities that support clinicians and 

pharmacists in prescribing and dispensing medications to patients. These 

capabilities are achieved with the use of multiple VistA and other 

computer applications that enable the processing and viewing of health 

data. Nevertheless, as a result of several limitations in VistA’s 

capabilities, pharmacists cannot always view the necessary patient data 

and transfer prescriptions among the department’s numerous medical 

centers, primary care clinics, and multi-specialty outpatient clinics.

Industry practices suggest that pharmacy systems should, among other 

things, include the capability to electronically create prescriptions and 

send them to pharmacies for the dispensing of medications. Guidance 

developed by the Office of the National Coordinator for Health Information 

Technology identifies specific capabilities that are key to having a 

pharmacy system that enables effectively creating and processing 

prescriptions. These include capabilities to review patient data, select and 

authorize medications, and send medication orders to pharmacies for 

processing.46 Accomplishing this depends on the system enabling 

clinicians and pharmacists to effectively view and share patient 

information and pharmacy data. A congressional report has emphasized 

the importance of VA being able to use its pharmacy systems to view 

data among VHA medical sites.47

VA’s current pharmacy system capabilities are being provided by 17 VistA 

pharmacy software applications 48 and CPRS49 which, collectively, enable 

clinicians and pharmacists to process, view, and share pharmacy data. 

 

46Department of Health and Human Services Office of the National Coordinator for Health 

Information Technology, A Prescription for e-Prescribers: Getting the Most Out of 

Electronic Prescribing, ONC Web Site. 

47Senate Committee Report 114-57. 

48VistA is comprised of 17 pharmacy applications that collectively support clinicians and 

pharmacists: Automatic Replenish/Ward Stock, Bar Code Medication Administration, Bar 

Code Medication Administration Backup Utility, Consolidated Mail Outpatient Pharmacy, 

Controlled Substances, Pharmacy Data Management, Drug Accountability/Inventory 

Interface, Electronic Claims Management Engine, Inpatient Medications, Inpatient 

Medications - Intravenous, Inpatient Medications - Unit Dose, National Drug File, 

Outpatient Pharmacy, Medication Order Check Healthcare Application, Pharmacy 

Enterprise Customization System,Pharmacy Benefits Management, Pharmacy Product 

System – National Registries.

49CPRS is a not a pharmacy-specific application but pharmacy functions are dependent 

on it. 

VA Has Pharmacy 

System Capabilities, 

but Inefficiencies 

Exist in Viewing and 

Transferring Data

VA Has Pharmacy System 

Capabilities for Prescribing 

and Dispensing 

Medications, but 

Inefficiencies Exist in 

Viewing Pharmacy Data
Page 17 GAO-17-179 VA Pharmacy IT

The department relies on these applications to support pharmacy 

services such as (1) processing and dispensing outpatient and inpatient 

medications to veterans; (2) processing and automatically transmitting

prescription data from VA medical centers to consolidated mail outpatient 

pharmacies; (3) monitoring and tracking the receipt, inventory, and 

dispensing of all controlled substances; and (4) alerting pharmacy 

personnel to the existence of medications that may have been prescribed 

at other facilities. For a description of applications that VA has 

categorized as VistA pharmacy applications, see appendix II.

Although multiple applications support pharmacy capabilities, clinicians 

and pharmacists primarily rely on three applications to prescribe and 

dispense outpatient medications: CPRS, the Medication Order Check 

Healthcare Application, and Outpatient Pharmacy.50

• CPRS provides clinicians the ability to prescribe medications as well 

as the ability to record patient data, including patients’ allergies or 

adverse reactions to medications.

• The Medication Order Check Healthcare Application enables 

clinicians and pharmacists to check new prescriptions to identify any 

interactions with other medications that the patient is currently taking, 

a process that is referred to as order checks. This application enables 

checks of new prescriptions for interactions at the medical site where 

the patient is being treated, as well as at other VHA medical sites. 

After the clinician prescribes the medications in CPRS, the Medication 

Order Check Healthcare Application is run instantaneously and the 

results of the check are displayed for the clinician to review and make 

any needed changes.

• Outpatient Pharmacy allows pharmacists to process and fill 

medication prescriptions from CPRS for veterans that are seen in 

outpatient clinics or that have received prescriptions upon discharge 

from a VA hospital. The application also enables pharmacists to 

review the results of the Medication Order Check Healthcare 

Application checks to ensure there are no allergies or interactions 

before filling the prescription.

 50Our review focused on outpatient prescriptions and corresponding systems. Clinicians 

and pharmacists do not directly interact with some of the 17 VistA pharmacy applications 

which support prescribing and dispensing medication with capabilities such as drug 

inventory, submitting prescriptions to a mail facility, and standardizing drug information in 

files used by local medical centers. 
Page 18 GAO-17-179 VA Pharmacy IT

In conjunction with the patient data that can be viewed in these VistA 

applications, three different viewing applications, or viewers, are available 

to clinicians and pharmacists for use in creating prescriptions and 

dispensing medications. These applications—Remote Data View, 

VistAWeb, and Joint Legacy Viewer—can be used by clinicians and 

pharmacists to view and share information from other VHA medical sites. 

Each of these read-only viewers provides slightly different capabilities.

• Remote Data View enables clinicians and pharmacists to view and 

share prescriptions, laboratory histories, radiological images, and 

reports of outpatient medications, which can be seen by clinicians and 

pharmacists at all VHA medical sites. Clinicians and pharmacists can 

access Remote Data View after logging on to the CPRS application.

• VistAWeb enables clinicians and pharmacists to view and share 

patient data, including prescriptions, lab history, limited radiological 

imaging, patient information from VA’s private health care providers, 

and reports of outpatient medications with all VHA medical sites. 

VistAWeb can be accessed separately in VistA or from the CPRS 

application.

• The Joint Legacy Viewer enables clinicians and pharmacists to view 

and share prescriptions, lab history, radiological imaging, patient 

information from VA’s private health care providers, and reports of 

outpatient medications with all VHA medical sites. The Joint Legacy 

Viewer provides access to DOD clinical notes, among other DOD 

data, that are not available using the other two viewers; it also offers 

the ability to integrate data and customize what is displayed. The Joint 

Legacy Viewer cannot be accessed from the CPRS application and 

requires a separate login.

Figure 3 provides a simplified depiction of the VistA applications and 

viewers that clinicians and pharmacists use to prescribe and dispense 

outpatient medications.
Page 19 GAO-17-179 VA Pharmacy IT

Figure 3: Simplified Depiction of the Department of Veterans Affairs’ Applications and Viewers for Prescribing and Dispensing 

Outpatient Medications

As shown in figure 3, clinicians and pharmacists follow separate 

workflows to, respectively, prescribe and dispense medications. 

Specifically, when prescribing a medication, a clinician uses CPRS to:

• select the patient being treated by using a patient selection screen.

• view information needed to assess the patient. Clinicians can use 

CPRS to view patient information such as active problems, allergies, 

and medications at the site where the patient is being treated. The 
Page 20 GAO-17-179 VA Pharmacy IT

patient information is displayed by CPRS to support the clinician’s 

treatment decisions.

• access the different viewers to view patient information from other 

VHA and DOD medical sites where the patient was treated and share 

additional patient information with other VHA locations.

• enter new prescriptions and other patient information, such as a 

patient’s allergies or adverse reactions to medications, progress 

notes, diagnoses, and treatments, which make up the patient’s 

electronic record.

• access the Medication Order Check Healthcare Application to view 

potential drug interactions and allergy data: when a clinician enters a 

prescription using CPRS, the system displays drug interactions 

identified by the Medication Order Check Healthcare Application 

instantaneously to alert clinicians to potential drug interactions, 

duplicate therapy, and maximum drug dosage.

• complete the prescription by approving and signing the prescription. 

The prescription then becomes available in the Outpatient Pharmacy 

application for processing and dispensing by a pharmacist.

To process and dispense outpatient prescriptions, a pharmacist uses the 

Outpatient Pharmacy application to:

• select a prescription for processing by accessing a list of outpatient 

prescriptions that were approved by clinicians.

• obtain additional patient information from CPRS or from one of the 

three viewers, and may also update prescription information in CPRS, 

such as the number of refills that remain for the patient. The 

pharmacist can also use the Outpatient Pharmacy application to view 

prescription and patient information, such as current and past 

medications and prescriptions that are ready to be dispensed to the 

patient.

• process the prescription by entering additional patient information, 

such as allergy data, reviewing the Medication Order Check 

Healthcare Application potential interactions, flagging the prescription 

if the pharmacist has questions for the clinician, and then entering 

prescription information, followed by verifying the prescription for 

dispensing.

• process, dispense, and generate prescription labels and reports that 

aid the pharmacist in controlling the medication inventory.
Page 21 GAO-17-179 VA Pharmacy IT

Nevertheless, while clinicians can view and share patient data to 

prescribe medications, pharmacists cannot always efficiently view patient 

data needed to dispense medications. As we found at selected VHA 

medical sites and during interviews with Pharmacy Benefits Management 

Services officials, when using the Outpatient Pharmacy application,51

certain limitations can hinder the pharmacists’ ability to view data:

• data continually rolls off the computer screen in order to make room 

for other information, which requires the pharmacists to continually

scroll through multiple screens to view pharmacy data; and

• additional time is required for the pharmacists to check and dispense 

medications because the pharmacists must switch between the 

Outpatient Pharmacy application and the data viewers in order to see 

all relevant patient information needed to dispense medications.

Pharmacy Benefits Management Services officials attributed these 

limitations to several factors: (1) the Outpatient Pharmacy application is 

outdated, as the core functionality was developed in the 1980s, with 

character-based input screens that have limited screen space and data 

that rolls off the computer screen; (2) the Outpatient Pharmacy 

application provides a character-based interface for users (i.e., the 

application requires text-based inputs to initiate actions), rather than a 

graphical user interface;52 and (3) the three data viewers are not 

integrated with the Outpatient Pharmacy application because the 

application was developed without a graphical user interface that could be 

used to select the viewers; thus the viewers need to be accessed in a 

separate screen.

VHA pharmacists have noted the lack of a graphical user interface as a 

limitation to efficiently processing prescriptions since 2001. Accordingly, 

Pharmacy Benefits Management Services officials stated that they have 

requested that the Outpatient Pharmacy application be modernized 

during VA’s annual process for requesting system updates. However, VA 

has not yet done so. According to the VistA Evolution modernization 

plans and Pharmacy Benefits Management Services officials, the 

 51For inpatients, the pharmacists use the Inpatient Medications to dispense medication 

and the Inpatient Medications screen presents information in a similar format, and thus 

has the same issues.

52Applications that are based on graphical user interface screens provide the ability to 

navigate the screen by using the mouse to point and click on selections, versus characterbased screens that require text entries to make selections.
Page 22 GAO-17-179 VA Pharmacy IT

department does not have plans to address this issue due to other reengineering priorities.

Until VA implements changes to its pharmacy system that address the 

inefficiencies with viewing patient information, pharmacists will continue to 

lack important capabilities that are essential to their reviews of patient 

data while processing and dispensing prescriptions.

Beyond limitations in viewing patient data, pharmacists lack the capacity 

to electronically transfer prescriptions to other VHA pharmacies or 

process prescription refills received from other VHA medical sites. 

According to the National Council for Prescription Drug Programs’

standards, systems should be able to electronically transfer prescriptions 

between pharmacies.53 However, pharmacists at the VHA medical sites 

we visited said patients that receive specialty care and prescriptions from 

a VHA medical site cannot have that prescription electronically 

transferred to their primary care site (the location that the veteran usually 

goes to), even if the different medical sites are in the same state. This is 

due to the fact that, as discussed in VA’s inbound e-prescribing project 

plans and with VHA pharmacists, CPRS and the VistA Outpatient 

Pharmacy application do not provide the capability to transfer 

prescriptions between pharmacies.

The department’s VistA modernization plans include acquiring by May 

2018, the capability to transfer prescriptions from one VHA pharmacy to 

another VHA pharmacy, as part of the inbound e-Prescribing project. In 

addition, the modernization plans call for the implementation of a new 

system—OneVA Pharmacy— that is to allow veterans to obtain 

prescription refills from a different VHA medical site. According to 

Pharmacy Benefits Management Services officials, VA is developing 

plans to implement this capability in September 2017.

If VA fully implements the prescription transfer capability as intended, 

pharmacists should then have an important tool to support the efficient 

and safe transfer of prescriptions and refills while ensuring that veterans 

receive prescriptions at the pharmacy of their choice in a timely manner.

 53National Council for Prescription Drug Programs, Standards Matrix, (January 2017).

Pharmacists Cannot 

Transfer Prescriptions to 

Other VHA Pharmacies
Page 23 GAO-17-179 VA Pharmacy IT

VA has developed various capabilities over the past two decades that 

have helped to advance interoperability between its own pharmacy 

system and DOD’s pharmacy system, thereby allowing clinicians and 

pharmacists to exchange certain patient and medication information. For 

example, the departments’ pharmacy systems provide the ability for 

clinicians and pharmacists to check prescription drug information for 

potentially adverse drug and allergy interactions. Nevertheless, certain 

limitations impede interoperability with DOD: VA clinicians and 

pharmacists (1) cannot always view DOD patient data and (2) do not 

always receive complete order checks 54 that include new DOD

medication data. Further, VA has not assessed the impact of its 

pharmacy system interoperability on service members transitioning care 

from DOD to VA.

The National Defense Authorization Act for Fiscal Year 2003 required VA 

and DOD systems to be interoperable, to achieve real-time interface and 

data exchange, and to have the ability to check prescription drug 

information for outpatients. Real-time interfaces can enable pharmacy 

and patient medical data to be viewed instantaneously after patient data 

is entered. In addition, complete patient information is needed for 

clinicians and pharmacists to make effective clinical decisions. The act 

also required that VA’s and DOD’s pharmacy systems have the ability to 

check prescription drug information for outpatients based on the use of 

national standards. To perform prescription order checks that include 

DOD patient data, the medication information has to be interoperable 

between DOD and VA systems.

To advance interoperability between their health information systems and 

adhere to the use of national standards, VA and DOD have mapped55

their medication data to the national standard RxNorm,56 thereby enabling 

 

54An order check enables clinicians and pharmacists to check new prescriptions to identify 

any interactions with other medications that the patient is currently taking.

55Mapping is the process of linking medication names and corresponding data to the 

names that are used in the national standards.

56DOD and VA identified RxNorm as the national standard terminology for medications. 

RxNorm, developed by the Department of Health and Human Services’ National Library of 

Medicine, provides normalized names for clinical drugs commonly used in pharmacy 

systems.

VA’s Pharmacy 

System Has Certain 

Interoperability 

Capabilities with 

DOD, but Limitations 

Reduce 

Effectiveness; VA Has 

Not Assessed the 

Impact of 

Interoperability

VA’s Pharmacy System 

Enables Interoperability 

Capabilities with DOD, but 

Clinicians and 

Pharmacists Cannot 

Always View Data or 

Receive Complete Order 

Checks
Page 24 GAO-17-179 VA Pharmacy IT

clinicians at each department to use their pharmacy systems to perform 

medication order checks to identify potential adverse effects, such as 

drug allergies and drug interactions. Further, as a result of various 

capabilities that the two departments developed over the past two 

decades, they are able to view and share pharmacy data in near realtime57 for transitioning service members or patients that receive care at 

both departments’ medical facilities. These capabilities include the:

• Bidirectional Health Information Exchange – built on the Federal 

Health Information Exchange framework,58 this mechanism allows VA 

and DOD clinicians to view real-time inpatient and outpatient clinical 

data for patients receiving treatment from both departments. The data 

shared through this exchange includes drug allergy, outpatient 

pharmacy, and inpatient information.

• Clinical Data Repository/Health Data Repository – as mentioned 

earlier, this is an interface that allows VA and DOD to share electronic 

health records from their respective health data repositories. This 

interface provides clinicians at both departments’ with bidirectional, 

real-time exchange of medical records,59 to include outpatient 

pharmacy and drug-allergy information that enables drug-to-drug and 

drug-allergy order checks.

Additionally, certain VistA applications (i.e., the Medication Order Check 

Healthcare Application, CPRS, and VistA Outpatient Pharmacy), along 

with the Joint Legacy Viewer, enable some level of interoperability 

between VA’s and DOD’s pharmacy systems by allowing clinicians and 

pharmacists to check prescription drug information for outpatients. 

Specifically, the Joint Legacy Viewer enables VA clinicians to view DOD 

data through a single interface. In addition, as mentioned previously, the 

Medication Order Check Healthcare Application enables clinicians and 

pharmacists to check on prescription drug data from both VA and DOD to 

 57Near real-time data requirements are based on the specified use case and means that 

the data is available after the delay is introduced by data processing or network 

transmission has elapsed.

58The Federal Health Information Exchange was completed in 2004 and enables DOD to 

electronically transfer service members’ health information, including outpatient pharmacy 

and drug-allergy data, to VA upon their separation from active duty. It provides a one-way 

batch transfer of text data from DOD to VA. This transfer occurs weekly if a discharged 

patient has been referred to VA for treatment; otherwise the transfer occurs monthly.

59Patients who have received treatment from both VA and DOD medical facilities within 

the past 3 years are marked in the system as shared patients or active dual consumers.
Page 25 GAO-17-179 VA Pharmacy IT

view drug-to-drug interactions and allergies for outpatients. If any such 

interactions are identified, the Medication Order Check Healthcare 

Application displays an alert in CPRS or the VistA Outpatient Pharmacy 

application. (Additional information on DOD and VA’s initiatives to share 

patient pharmacy data is discussed in appendix III.)

Nevertheless, while these capabilities exist, VA clinicians and 

pharmacists face limitations in that they cannot always view patients’

data. Specifically, DOD patient data does not always populate in the 

Remote Data View even though a record exists for the veteran. In 

addition, we observed during our site visits that the Joint Legacy Viewer 

could not always connect to DOD’s pharmacy system and display the 

patient’s medical data. As demonstrated at these sites, when DOD data 

did not populate in one of the viewers, VA clinicians and pharmacists had 

to either recheck the viewer that failed to display the DOD data or check 

one of the other two viewers.

VHA officials stated they could not explain the reasons that clinicians and 

pharmacists could not always view DOD data as we observed during our 

site visits without additional information. Specifically, they would need 

information regarding how the data was requested to identify and address 

any system limitations. The officials also stated that the department had 

conducted assessments of the accuracy and completeness of the data 

exchanged between the two departments from October 2014 to May 

2015. However, they discontinued the assessments due to other priorities 

and have not since conducted any such assessments. Until VA ensures 

that its clinicians and pharmacists can view all necessary DOD patient 

records, they may not have complete information for making effective 

clinical decisions about prescriptions which, in turn, may cause 

unnecessary delays in providing medical care to veterans and eligible 

service members.

In addition, VA pharmacists and clinicians do not always receive complete 

information from DOD’s pharmacy system that is needed to perform 

medication order checks on new medications. Specifically, they face 

limitations in receiving the results of medication order checks based on 

DOD data when accessed through CPRS and the VistA Outpatient 

Pharmacy. To facilitate medication information interoperability, both 

departments currently map and update their medication information to 

ensure it is consistent with national standards every month. However, 

since the timing of the updates for each department’s mapping to the 

national standards may not always be the same, order checks cannot 
Page 26 GAO-17-179 VA Pharmacy IT

always be performed for new medications that have not been mapped to 

the national standards.60

Incomplete order checks are, in part, due to the fact that VA uses data 

mapping instead of using standardized medication terminology in its 

pharmacy system (this process is referred to as native standardization).61

According to VA’s interoperability plan, the department is using mapping 

as an interim approach in order to meet the requirements of the National 

Defense Authorization Act for Fiscal Year 2003, which states that VA and 

DOD should use national standards to exchange outpatient medication 

information.

VHA officials said they recognized that mapping limits standardization 

and had started to use native standardization for certain data, such as 

immunizations, labs, problem lists, and encounter data.62 In addition, 

according to VA’s interoperability plan, the department has started, but 

has not yet completed a plan for implementing native standardization for 

medication and allergy data that is necessary to conduct order checks for 

duplicate medications, medication allergies, and medications that exceed 

the maximum dosage amounts. The officials could not tell us when the 

department expects to complete this plan.

Until the department reduces the risk of incomplete order checks by 

completing its plan to implement an approach to using national standards 

for medication and allergy data, its clinicians and pharmacists will 

continue to receive incomplete order checks, which may present risks to 

patient safety.

 60For example, in November 2016, 1,807 out of 11,577,190 (0.016 percent) health data 

exchange transactions failed because of the time lag in data mapping at the departments.

61Native standardization is an alternative approach to mapping. In native standardization, 

the medication names used in VA’s databases are the same as the medication names 

specified by the national standard, which eliminates ambiguity that can occur when there 

are multiple names used for the same medication.

62An encounter is a contact between a patient and a provider who has primary 

responsibility for assessing and treating the patient at a given contact, exercising 

independent judgment. A patient may have multiple encounters per visit. Outpatient 

encounters include scheduled appointments and walk-in unscheduled visits. A clinician’s 

telephone communications with a patient may be represented by a separate encounter. If 

the patient is seen in an outpatient clinic while an inpatient, this is treated as a separate 

encounter. Encounter data includes appointment and admissions data.
Page 27 GAO-17-179 VA Pharmacy IT

According to the Office of Management and Budget guidelines,63 an 

agency is to conduct assessments of its systems to analyze how 

organizational assets, such as IT systems, are able to support the 

organization’s mission. A key aspect of VA’s organizational mission 

includes providing pharmacy benefits to transitioning service members, 

which relies on having interoperability between VA and DOD’s systems.

However, the impact of VA’s interoperable pharmacy system capabilities 

on transitioning service members is not known because the department 

has not conducted such an assessment. While the department performed 

an operational analysis 64 in fiscal year 2015 for its overall medical IT 

support investment, the analysis did not address interoperability 

capabilities of systems, such as the Medication Order Check Healthcare 

Application, CPRS, or VistA Outpatient Pharmacy, and their impact on the 

care being provided to transitioning service members.

VHA officials in the National Center for Patient Safety stated that it is 

difficult to assess system impact on veterans’ care and to link adverse 

medical events in patient care to the pharmacy system because there 

may be other contributing factors, such as personnel fatigue, team 

members’ dynamics, or training of the staff. While such factors are 

relevant, as previously discussed, we identified pharmacy system 

limitations in VA and DOD interoperability and in medical data mapping, 

which hindered VA clinicians’ and pharmacists’ ability to view DOD data. 

Both of these limitations prevent the VA clinicians’ and pharmacists’

ability to consistently obtain prescription information necessary to perform 

drug-to-drug checks and to make informed clinical decisions on patient 

care.

Thus, without an assessment, VA cannot be assured of the potential 

impact on veterans as a result of the interoperability of its pharmacy 

system with DOD’s system. Further, in the absence of such an 

assessment, VA lacks assurance regarding the effectiveness of its 

 63Office of Management and Budget, Capital Programming Guide, Supplement to Office of 

Management and Budget Circular A-11: Planning, Budgeting, and Acquisition of Capital 

Assets (Washington, D.C.: July 2016).

64Operational analysis is used for performance evaluation of an investment against an 

established set of cost, schedule, and performance goals. According to the Office of 

Management and Budget guidance, the analysis should focus on whether the investment 

supports customer processes as designed.

VA Has Not Assessed the 

Impact of Pharmacy 

System Interoperability on 

Transitioning Service 

Members
Page 28 GAO-17-179 VA Pharmacy IT

pharmacy system to adequately support its mission of providing health 

care to veterans.

Industry practices that have been suggested for improving the efficiency 

and effectiveness of clinicians and pharmacists in prescribing and 

dispensing medications include the six selected practices identified earlier 

in this report. These practices focus on enabling clinicians and/or 

pharmacists to (1) order medications electronically, (2) receive drug-todrug and drug-allergy interaction checks, (3) track the dispensing of 

controlled prescription drugs, (4) electronically exchange prescriptions 

with non-VA entities (i.e., private or DOD clinicians and pharmacies), (5) 

utilize clinical decision support capabilities, and (6) maintain a perpetual 

inventory management capability to monitor medication inventory levels.

We found that VA implemented pharmacy system capabilities that align 

with three of these six practices. Specifically, as discussed earlier, the 

department’s current pharmacy system capabilities incorporate two 

practices: the ability for clinicians to order medications electronically and 

to receive drug-to-drug and drug-allergy interaction checks. In this regard, 

VistA and CPRS provide the ability for clinicians to electronically order 

patient medications at local VHA sites and for clinicians and pharmacists 

to receive drug-to-drug and drug-allergy interaction checks through the 

Medication Order Check Healthcare Application. The Medication Order 

Check Healthcare Application also provides order checks for duplicate 

therapy and maximum single dose order checks. According to VA’s 

Pharmacy Re-engineering plans, VA intends to implement the ability for 

the Medication Order Check Healthcare Application to deliver maximum 

daily dose65 order checks for clinicians and pharmacists beginning in May 

2018.

Further, VA has taken steps related to a third industry practice to track the 

dispensing of controlled prescription drugs through state-run prescription 

monitoring drug programs.66 According to Pharmacy Benefits 

Management Services officials, and based on our visits to selected 

medical sites, VA currently sends data on prescriptions for controlled 

 65If a dose range order check with a maximum daily dose limit can be calculated, then a 

warning message will be displayed for orders which a daily dose of a medication exceeds 

the recommended maximum daily dose.

66Department of Health and Human Services, Prescription Drug Monitoring Program 

Interoperability Standards, A Report to Congress (September 2013). 

VA’s Pharmacy 

System Incorporates 

Some Health Care 

Industry Practices, 

but Not Others
Page 29 GAO-17-179 VA Pharmacy IT

substances to 47 state programs.67 The officials added that the 

department plans to begin sending controlled substance prescription data 

to 3 additional state programs when appropriate agreements have been 

established.68

To retrieve data from the state prescription monitoring drug programs, VA 

clinicians manually access the state prescription monitoring databases 

and document that they accessed these databases in the patient’s file. 

According to the user manuals for VA’s CPRS, Medication Order Check 

Healthcare Application, and VistA Outpatient Pharmacy, the clinicians 

receive alerts warning them of duplicate orders for controlled substances 

via these applications; the alerts prompt them to review data from the 

state prescription monitoring databases. Clinicians at the sites we visited 

use a template in CPRS that identifies clinical warning signs of potential 

controlled substance abuse.

While VA’s system includes capabilities that are consistent with three of 

the selected industry practices, the department has not implemented 

capabilities that align with three other selected practices that could 

enhance its pharmacy system’s usefulness. Specifically, it has not 

implemented practices related to electronically exchanging prescriptions 

with non-VA entities (e.g., private or DOD), using certain clinical decision 

support capabilities, and maintaining a perpetual inventory management 

capability to monitor medication inventory levels.

According to the Office of the National Coordinator for Health Information 

Technology, health IT systems should enable a user to electronically 

send prescriptions to, or receive them from, non-VA providers and 

pharmacies in accordance with National Council for Prescription Drug 

Programs standards.69 The Office of the National Coordinator for Health 

 67These programs are in 46 states and the District of Columbia.

68VA has plans to send data to Nebraska, New Mexico, and New York. One state, 

Missouri, has not established a prescription drug monitoring program.

6980 Fed. Reg. 62640, 62750 (Oct. 16, 2015), and Office of the National Coordinator for 

Health IT, 2016 Interoperability Standards Advisory (January 2016). The National Council 

for Prescription Drug Program includes the SCRIPT standard to facilitate the transfer of 

prescription data between pharmacies, prescribers, intermediaries, facilities, and payers. 

Within this standard, basic business operations, such as the communication of 

prescription information between prescriber and pharmacy, and medication history 

information between entities can all be handled electronically (computer to computer).

VA’s Pharmacy System 

Has Not Incorporated 

Three Practices That 

Could Enhance Its 

Usefulness

VA’s System Does Not 

Electronically Exchange 

Prescriptions with Non-VA 

Entities
Page 30 GAO-17-179 VA Pharmacy IT

Information Technology also stated that electronic prescriptions should 

have the capability to include key information, such as the reason for the 

prescription, the diagnosis, and the ability to transmit the prescription in a 

secure manner. This is important to prevent the risk of loss or 

misinterpretation, which may occur with hand-written prescriptions.

However, CPRS and the VistA Outpatient Pharmacy application do not 

have the functionality that would enable clinicians or pharmacists to 

electronically receive prescriptions from non-VA providers or non-VA 

pharmacies (private or DOD).70 In addition, these applications do not 

have functionality that enables clinicians or pharmacists to send 

prescriptions to external providers and pharmacies, which are referred to 

as outbound prescriptions. As a result, veterans must obtain paper 

prescriptions or have prescriptions faxed from non-VA providers, and 

submit the prescriptions to their local VA medical sites in order for the VA 

pharmacy to manually input the prescriptions into the system and fill 

them—a process that is time consuming and inefficient.

VA has recognized the need to exchange prescriptions with non-VA 

providers and pharmacies, and has plans to include the capability to 

receive electronic prescriptions and use the National Council for 

Prescription Drug Programs standards in the VistA Outpatient Pharmacy 

application. Specifically, according to Pharmacy Re-engineering 

documentation, its Inbound ePrescribing project is intended to provide the 

ability to receive electronic prescriptions from a non-VA provider or a nonVA pharmacy.

According to the VistA 4 Roadmap,71 the Inbound ePrescribing project

was originally planned for national deployment in March 2016. VA officials 

from the Office of Information and Technology stated that they began 

 70The Veterans Access, Choice, and Accountability Act, enacted in August 2014,required 

VA to establish a program to improve veterans’ access to health care by allowing eligible 

veterans to use eligible health care providers outside of the VA system. Instances in which 

a veteran would be eligible include those in which the veteran is told by his or her local VA 

medical facility that he or she will need to wait more than 30 days from the preferred or 

medically determined date, or if the veteran’s current residence is more than 40 miles from 

the nearest VA medical facility. Through the Choice Program, a non-VA provider may 

issue a prescription to be filled at any non-VA pharmacy up to a 14 day supply.For 

prescriptions past 14 days, veterans are to follow standard procedures to fill a prescription 

at the VA pharmacy. According to pharmacists at our site visits, significant time and 

resources were required to process prescriptions for the program’s patients.

71Department of Veterans Affairs, VistA 4 Roadmap, Version 3.11 (Feb. 26, 2015).
Page 31 GAO-17-179 VA Pharmacy IT

development of inbound electronic prescribing capabilities in July 2016. 

However, the initiative was delayed because the technical system 

infrastructure was not available to support the initiative. Among other 

actions, these officials said VA needed to redefine technical requirements 

for the acquisition process and rebaseline and reapprove planning 

documents. The department now plans to begin to release this 

functionality in August 2017.

On the other hand, with regard to sending electronic prescriptions to nonVA pharmacies, VA does not yet have plans to implement outbound 

electronic prescribing capabilities. Pharmacy Benefits Management 

Services officials stated that doing so would require complex 

modifications to CPRS, or changes to the Enterprise Health Management 

Platform, which VA is in the initial stages of deploying.

However, without outbound electronic prescribing capabilities, VA’s ability 

to electronically send prescriptions to non-VA pharmacies is limited and 

the department faces increased risk that a clinician’s prescription will not 

be entered correctly at a non-VA pharmacy. This could lead to the wrong 

medication being dispensed or other patient safety issues, including 

dosing mistakes. In addition, veterans may face inconvenience because 

their prescriptions are not electronically transmitted to private pharmacies.
Page 32 GAO-17-179 VA Pharmacy IT

As previously discussed, Gartner’s Generation Model for Enterprise 

Electronic Health Record systems 72 is a framework where generation 

level 373 calls for establishing effective clinical decision support 

capabilities,74 clinical workflow,75 and clinical display,76 as well as 

computer-based physician order entry. In robust electronic health record 

systems, ordering medication is tightly connected to clinical decision 

support. Clinical decision support helps clinicians make complex 

decisions and can trigger appropriate early notification of possible 

untoward events.

VA’s health information system, VistA, including CPRS, does not have 

capabilities that could enhance clinical decision support for patient 

treatment. Moreover, while VA has undertaken a new initiative to address 

these deficiencies, the initiative is not in clinical use and its plans are 

incomplete. According to VA documentation, a 2011 evaluation found that 

VistA and CPRS did not have generation level 3 capabilities and noted 

that, compared to commercial solutions, VistA lagged with regard to key 

clinical functionalities such as clinical decision support, clinical display, 

 72Gartner, Gartner’s Update to the Enterprise Electronic Health Record Generation Model, 

(August 2016).Gartner uses a generation model to track the progression in capabilities of 

electronic health record systems evolving from very simple systems that provide results 

reporting tools to complex, fully integrated systems that clinicians can use to help facilitate 

the practice of evidence-based medicine. Gartner first introduced a five-stage enterprise 

electronic health record generation model in 1998, updated the model in 2007, and more 

recently in 2016.

73Generation level 3 electronic health record systems are complex systems designed to 

allow clinicians more direct interaction and help facilitate the practice of evidence-based 

medicine. Electronic health record systems at this level must provide functionality for 

ambulatory and all acute care settings, and have effective clinical decision support, 

workflow capacity for care plans, and clinical documentation and display, as well as 

computer-based physician order entry.

74Clinical decision support helps clinicians make complex decisions and can trigger 

appropriate early notification of possible untoward events.

75Automation systems must provide support for the processes involved in clinical care, as 

well as the information needed. Electronic health record (clinical) workflow capabilities 

enable the health delivery organization to define key processes in such a manner that the 

electronic health record can then assist humans and automated systems in reliably 

carrying out these processes.

76Once captured, data must be presented in a meaningful manner that contributes to the 

clinician's ability to use the data effectively.

VA’s System Does Not Include 

Certain Clinical Decision 

Support Capabilities; Plans for 

Implementation Are Incomplete
Page 33 GAO-17-179 VA Pharmacy IT

and clinical workflow.77 For example, VistA does not always display data 

in a meaningful manner that contributes to the clinician’s ability to use the 

data effectively. VA also identified that CPRS has limited capability for 

presenting patient information recorded at DOD and other VHA medical 

sites in a manner that supports clinicians’ effective use of patient data. In 

this regard, data such as laboratory tests and medications are currently 

not available for viewing on the same screen, but should be considered 

together to improve the understanding of how medications affect 

patients.78

In order to provide clinicians and pharmacists with more clinical decision 

support and to help with patient treatment, in 2014, VA initiated 

development of the Enterprise Health Management Platform, which 

according to the system design document, is a multi-year effort to 

modernize the department’s electronic health record system and replace 

parts of CPRS. The current version of the Enterprise Health Management 

Platform is to have capabilities for clinicians to view patient data from both 

VA and non-VA providers and pharmacies on a single screen, and for 

clinicians to customize the screen—enabling data such as laboratory 

tests and medications to be displayed together—to meet the clinician’s 

data needs. By addressing the existing limitation of laboratory and test 

data not being available on a single screen when creating prescriptions, 

the Enterprise Health Management Platform is expected to provide a 

clinical decision support capability that improves the clinicians’ ability to 

consider all relevant information when creating prescriptions. According to 

VA officials, these capabilities are currently being tested.

Nevertheless, while the Enterprise Health Management Platform will 

include some generation level 3 clinical capabilities, such as those 

mentioned above, it is currently not in clinical use and does not have 

additional capabilities that could make the pharmacy system more useful 

to clinicians and pharmacists, and enhance clinical decision support and 

clinical display. These capabilities include the ability to proactively alert a 

clinician that medication dosage may need to be adjusted based on 

medical test results, which would help ensure that medication is 

 77Department of Veterans Affairs, Health Information Strategic Plan for Veterans Health 

Administration Supporting VA Health Care Fiscal Year 2014-2019, Version 2.4 (July 2014) 

and Gartner Consulting, VistA Comparison to the Commercial Electronic Health Record 

Marketplace Final Report, (Feb. 4, 2011).

78Department of Veterans Affairs, Enterprise Health Management Platform (eHMP) 

System Design Document, Version 2.16 (Sept. 2016).
Page 34 GAO-17-179 VA Pharmacy IT

prescribed based on current medical information for patients, and the 

ability to navigate from an alert directly to a new medication order screen 

to change the medication.

While VA has plans and time frames for implementing the capability to 

proactively alert a clinician about medication dosages, VHA officials did 

not have specific time frames or milestones for when the ability to 

navigate from an alert to medication order is expected to be achieved. 

The officials stated that they did not yet have time frames for this effort 

because the department is evaluating alternatives for its future electronic 

health record system. Nevertheless, until VA implements certain clinical 

decision support capabilities, such as the ability to navigate from an alert 

directly to a new medication order screen, VA clinicians and pharmacists 

will lack important capabilities that could enhance clinical decisions 

related to prescribing medications.

Industry practices stress the use of a computerized system to manage 

perpetual inventory so that the system displays up-to-date pharmaceutical 

inventory at all times.79 This includes the capability to, when dispensing or 

restocking medication, update the inventory totals to accurately reflect the 

amount of medication that is in stock, and to set minimum inventory levels 

for medications that, when reached, alert the pharmacy to reorder the 

medication.

However, VistA does not include a perpetual pharmaceutical inventory 

management system to monitor the inventory of VA’s pharmacy 

medications. Specifically, the pharmacy system cannot consistently 

update inventory totals to accurately reflect the amounts in stock and 

cannot set minimum inventory amounts for automated reordering of 

medication. For example, pharmacists at sites that we visited said that the 

automated machines they rely on to dispense medication are not 

integrated with their inventory systems, resulting in labor-intensive 

processes for updating and tracking when to reorder medications. 

Further, a VHA pharmacist at one site stated that, compared to 

commercial retail pharmacies, when dispensing medication, VA’s 

pharmacy system does not have automated updates to the inventory total 

to reflect that medication was dispensed (with the exception of controlled 

substances which they monitor closely). In addition, according to 

 79A. K. Ali, “Inventory Management in Pharmacy Practice: A Review of Literature” 

Archives of Pharmacy Practice. Vol. 2 Issue 4 (2011).

VA’s System Does Not 

Maintain a Perpetual Inventory 

to Monitor Medication 

Inventory Levels
Page 35 GAO-17-179 VA Pharmacy IT

Pharmacy Benefits Management Services officials, VA’s pharmacy 

system does not have the capability to set automated reorder levels so 

that pharmacists receive an automated alert to reorder medication when 

inventory levels drop to a specified amount.

According to VHA officials, the department has not prioritized requests to 

develop inventory management capabilities, although plans and funding 

requests for these capabilities were included in the original Pharmacy Reengineering plans and have been resubmitted for inclusion in the budget 

by Pharmacy Benefits Management Services officials annually since 

2009. Pharmacy Benefits Management Services officials added that, 

other priorities, such as the development of the Medication Order Check 

Healthcare Application, have prevented VA from replacing inventory 

management system capabilities, as originally planned in 2002. However, 

without the ability to monitor and update the inventory of pharmacy 

medications, VHA pharmacists lack the means to effectively track when to 

reorder medications, which can potentially impact patient’s health care 

and safety.

VA currently uses VistA and multiple other computer applications to 

support clinicians and pharmacists in prescribing and dispensing 

medications to patients. However, inefficiencies exist in the ability of VA 

pharmacists to view patient medication data between the department’s 

pharmacy systems, which limits their ability to efficiently process and 

dispense medications. Most notably, the Outpatient Pharmacy application 

lacks a graphical user interface and, therefore, pharmacists must take 

additional steps to view all the necessary information. While pharmacists 

have requested a modernized graphical user interface since 2001, VA 

has not developed one, nor does it have plans to do so going forward. 

However, until pharmacists can efficiently view all necessary medication 

data, there is a risk that veteran’s safety may be compromised.

In addition, VA has implemented capabilities to exchange patient data 

with DOD via the Joint Legacy Viewer and other sharing initiatives. 

Nevertheless, VA continues to face limitations in the ability to receive and 

use DOD data: clinicians and pharmacists cannot always view DOD 

patient data and VA pharmacists cannot always receive complete order 

checks from DOD for new medications. Until the department addresses 

these limitations in viewing DOD patient data and receiving complete 

order checks from DOD, clinicians and pharmacists will continue to lack 

the tools to make efficient clinical decisions about prescriptions, which 

could negatively affect patient safety. Moreover, VA has not assessed the 

Conclusions
Page 36 GAO-17-179 VA Pharmacy IT

impact that these shortcomings and its pharmacy system interoperability 

with DOD have on veterans. Without an assessment of the impact of its 

pharmacy system interoperability with DOD on veterans, VA will be 

hindered in its ability to determine the effectiveness of delivering 

pharmacy services and the potential impact on veterans.

Finally, while VA’s pharmacy system incorporates some industry 

practices, it lacks other capabilities, such as electronic prescribing, certain 

clinical decision support, and inventory management, which could 

enhance the system’s usefulness. VA has plans to address part of the 

electronic prescribing capability, but the plans are incomplete since they 

do not address outbound prescriptions sent to non-VA pharmacies. VA’s 

planned Enterprise Health Management Platform is expected to position 

the department to achieve clinical decision support capabilities; but the 

platform is not in clinical use and there is uncertainty about VA’s 

implementation approach for delivering these important capabilities. 

Further, VA has not prioritized the development of pharmacy system 

capabilities to update and monitor inventory needed to track when to 

reorder medications. Lacking these capabilities, the department will 

continue to be limited in its ability to exchange prescriptions with non-VA 

providers, provide additional clinical decision support, and track

medication which could impact veteran patient safety.

To provide clinicians and pharmacists with improved tools to support 

pharmacy services to veterans and reduce risks to patient safety, we 

recommend that the Secretary of Veterans Affairs direct the Assistant 

Secretary for Information and Technology and the Under Secretary for 

Health to take the following six actions:

• establish and implement a plan for updating the pharmacy system to 

address the inefficiencies with viewing patient medication data in the 

Outpatient Pharmacy application and between the pharmacy 

application and viewers;

• complete a plan for the implementation of an approach to data 

standardization that will support the capability for clinicians and 

pharmacists to view complete DOD data and receive order checks 

that consistently include DOD data;

• conduct an assessment to determine to what extent interoperability of 

VA’s pharmacy system with DOD’s pharmacy system is impacting 

transitioning service members;

Recommendations for 

Executive Action
Page 37 GAO-17-179 VA Pharmacy IT

• develop and execute a plan for implementing the capability to send 

outbound e-prescriptions to non-VA pharmacies, in accordance with 

National Council for Prescription Drug Programs standards;

• ensure that the department’s evaluation of alternatives for electronic 

health records includes consideration for additional generation level 3 

capability such as navigating from an alert to medication order in the 

electronic health record system; and

• reassess the priority for establishing an inventory management 

capability to monitor and update medication levels and track when to 

reorder medications.

We provided a draft of this report to VA, DOD, and HHS for their review 

and comment. In its written comments on a draft of this report (reprinted 

in appendix IV), VA generally concurred with our six recommendations

and described various actions that it planned to take to address the 

recommendations. DOD provided technical comments, which we 

incorporated into our report as appropriate. HHS did not provide 

comments.

After VA received our draft report, VHA officials expressed concerns with 

the wording of our second recommendation (pertaining to completing a 

plan for the implementation of an approach to data standardization that 

will support the capability for clinicians and pharmacists to view complete 

DOD data and receive order checks that consistently include DOD data).

VHA officials noted that the recommendation required actions by DOD in 

addition to the actions directed specifically at VA. Based on further 

discussion with these officials, we revised our second recommendation to 

emphasize the importance of VA completing a plan for the 

implementation of an approach to data standardization that will support its 

clinicians and pharmacists in viewing complete DOD data and receiving 

order checks that consistently include DOD data. In its written comments 

that addressed the revised recommendation, the department stated that it 

concurred in principle with this recommendation. In this regard, the 

department stated that, while viewing complete DOD data is essential for 

the safe care of veterans, VA’s consistent viewing of DOD pharmacy data 

is dependent on that department’s completion of its data interoperability 

initiatives. VA added that, in the interim, both departments are planning 

enhancements to the joint DOD/VA Clinical Health Data Repository to 

improve the exchange of pharmacy data between VA and DOD, and plan 

to complete this effort in fiscal year 2018. 

Agency Comments 

and Our Evaluation
Page 38 GAO-17-179 VA Pharmacy IT

We are sending copies of this report to the Secretary of Veterans Affairs 

and other interested parties. In addition, the report is available at no 

charge on the GAO website at http://www.gao.gov. 

If you or your staff have any questions about this report, please contact 

me at (202) 512-6304. I can also be reached by e-mail at 

melvinv@gao.gov. Contact points for our Offices of Congressional 

Relations and Public Affairs may be found on the last page of this report. 

GAO staff who made key contributions to this report are listed in 

appendix V.

Valerie C. Melvin

Managing Director

Information Technology
Appendix I: Objectives, Scope, and 

Methodology

Page 39 GAO-17-179 VA Pharmacy IT

The Senate Appropriations Committee Report accompanying the 

Consolidated Appropriations Act for fiscal year 2016 called for us to 

examine the Department of Veterans Affairs’ (VA) acquisition and use of 

a pharmacy data system.1 Our objectives were to determine whether: (1) 

VA currently possesses a functioning pharmacy system and the extent to 

which the system enables data to be viewed, shared, and transferred 

among Veteran’s Health Administration (VHA) pharmacy locations; (2) 

VA’s pharmacy system is interoperable with the Department of Defense’s 

(DOD), and whether this system, or the absence thereof, is impacting 

service members who transition care from DOD; and (3) VA has 

implemented its pharmacy system in accordance with health care industry 

practices.

To address the first objective, we obtained and analyzed documentation 

on VA’s pharmacy system, such as technical manuals and architecture 

diagrams, which showed the current and planned capabilities of the 

pharmacy system. We analyzed the documents to identify the key 

systems that VHA clinicians and pharmacists used to order and dispense 

medication, and to assess system capabilities for viewing patient data 

and medication, both at a veteran’s home facility where most care is 

provided as well as at other VHA facilities. We also assessed system 

capabilities of the Pharmacy Outpatient application with a focus on 

outpatient care because about 70 percent of prescriptions are for 

outpatient use.

We validated our initial assessments through observing demonstrations of 

the pharmacy system at VA medical centers in Baltimore, Maryland; 

Butler, Pennsylvania; and San Antonio, Texas; and at a joint VA and DOD 

health center in North Chicago, Illinois. During these site visits, we 

reviewed how the system enables the viewing, sharing, and transferring 

of pharmacy data between VHA locations. Our criteria for selecting these 

sites was intended to ensure coverage of: (1) different geographic 

locations, (2) the variety of VA facilities (e.g., a medical center and an 

independent outpatient clinic), and (3) a location piloting the new VA 

enterprise health platform (the Enterprise Health Management Platform). 

 1S. Rep. No.114-57 at 61-62 (2015). The Senate committee requested GAO to review 

whether VA currently possesses a functioning pharmacy data transaction system. The 

committee references the Bob Stump National Defense Authorization Act (NDAA) for 

fiscal year 2003, which referred to VA’s pharmacy data system. We use the term 

pharmacy system in our report to avoid confusion with a DOD system named the 

Pharmacy Data Transaction Service.

Appendix I: Objectives, Scope, and 

Methodology
Appendix I: Objectives, Scope, and 

Methodology

Page 40 GAO-17-179 VA Pharmacy IT

Additionally, each of the sites we selected had an on-site pharmacy. Our 

selection of medical sites ensured that we included diverse geographic 

locations of varying sizes and breadth of medical services offered.

At the sites, we met with clinicians, including doctors, nurses, and clinical 

pharmacists, and with pharmacists who review and dispense orders for 

prescriptions. We conducted site visits at medical facilities where we 

discussed the processes and corresponding systems and data viewers 

that clinicians and pharmacists used to provide health care to veterans, 

as well as what was working well and if there were any limitations of the 

system in conducting their work. In addition, we obtained the perspectives 

of officials representing VA’s Pharmacy Benefits Management Services 

and Office of Information and Technology on the strengths and limitations 

of the department’s pharmacy system, the underlying causes of any 

limitations, and plans to address the limitations.

To address the second objective, we reviewed VA technical manuals, 

architecture diagrams, and documents produced by the VA/ DOD 

Interagency Program Office.2 We also analyzed VA’s plans and identified 

its actions taken toward achieving interoperability with DOD; we then 

compared the department’s actions to certain requirements specified in 

the fiscal year 2003,3 2008,4 and 20145 National Defense Authorization 

Acts. Specifically, we reviewed VA responses and documentation on:

• data exchange mechanisms and services,

• implementation and use of national standards in pharmacy systems,

• pharmacy data checking,

• pharmacy system metrics such as availability, and

• pharmacy system testing.

 2The VA/DOD Interagency Program Office was put in place to be accountable for VA’s 

and DOD’s efforts to achieve interoperability.

3Pub. L. No. 107-314, § 724, 116 Stat. 2458, 2598 (2002). In 2005, GAO found that 

completion of VA’s pharmacy prototype satisfied the sec. 724 mandate.GAO, ComputerBased Patient Records: VA and DOD Made Progress, but Much Work Remains to Fully 

Share Medical Information, GAO-05-1051T (Washington, D.C.: Sept. 28, 2005).

4Pub. L. No. 110-181, § 1635, 122 Stat. 3, 460-463 (2008).

5Pub. L. No. 113-66, Div. A, Title VII, § 713, 127 Stat. 672, 794-798 (Dec. 26, 2013).
Appendix I: Objectives, Scope, and 

Methodology

Page 41 GAO-17-179 VA Pharmacy IT

We observed VA clinicians’ and pharmacists’ use of the VA and DOD 

systems at our selected sites to determine whether they could exchange 

pharmacy data in real-time and perform prescription drug interaction 

checks for outpatients. We also observed pharmacy capabilities of the 

DOD systems, and how those systems access VA data, at the joint VA 

and DOD health center in North Chicago, Illinois, and during two system 

demonstrations in Washington, D.C.

Additionally, we reviewed VA documentation to see how the department 

was monitoring and checking prescription drug data that is exchanged 

with DOD. We also evaluated whether VA systems used national 

standards for the exchange and mapping of outpatient medication 

information between VA and DOD. We obtained written responses from 

VA to questions on interoperability and reviewed VA reports and 

documents, including a report to Congress on interoperability standards, 

to evaluate the extent of pharmacy system conformance to national 

standards for the exchange of outpatient medication information between 

VA and DOD.

Further, we selected and contacted Veterans Service Organizations to 

determine whether they could provide information on the impact of 

interoperability of VA and DOD systems on veterans. We selected 

organizations that (1) we had identified in our prior work related to 

transitioning service members, (2) represented veterans from recent 

conflicts, and (3) were referred to us by VA or other Veterans Service 

Organizations. This resulted in the selection of six organizations for our 

review, which we determined had not reported on the impact of VA and 

DOD pharmacy information technology (IT) systems interoperability on 

veterans.

Lastly, to address the third objective we took the following steps to 

identify best practices of the health care industry. We conducted literature 

searches, reviewed our prior work, and consulted with the Department of 

Health and Human Services’ Office of the National Coordinator for Health 

Information Technology, VA’s Pharmacy Benefits Management Services 

and a private provider.6 We reviewed the Office of the National 

 6Kaiser Permanente Medical Care Program is an integrated health care delivery system 

that jointly works with VA to provide care to veterans. Kaiser Permanente was part of a 

pilot program in 2009 connecting Kaiser and VA’s electronic health record systems.
Appendix I: Objectives, Scope, and 

Methodology

Page 42 GAO-17-179 VA Pharmacy IT

Coordinator for Health Information Technology7 2015 Edition Health 

Information Technology Certification Criteria,8 and its 2016 

Interoperability Standards Advisory to identify the standard for electronic 

prescribing. We also reviewed the Office of the National Coordinator for 

Health Information Technology’s report to Congress on the prescription 

drug monitoring program interoperability standards.9 Further, we reviewed 

the 2014 National Defense Authorization Act,10 Gartner’s Update to the 

Enterprise Electronic Health Record Generation Model,11 standards set 

by the National Council for Prescription Drug Programs,12 and 

publications from the American Society of Health-System Pharmacists,13

and the Archives of Pharmacy Practice.14

 7This office is charged with formulating the federal government’s health IT strategy and 

coordinating related policies, programs, and investments. Through a regulatory process, it 

authorizes certification bodies to (on its behalf) certify whether health IT, including 

electronic health record systems, meet certain functional and technical requirements, 

including conformance to standards and implementation specifications. Providers that 

participate in the Medicare and Medicaid electronic health record incentive programs must 

demonstrate that they are “meaningful users” of certified electronic health record 

technology.

880 Fed. Reg. 62,602 (Oct. 16, 2015). Department of Health and Human Services, 2015 

Edition Health Information Technology (Health IT) Certification Criteria, 2015 Edition Base 

Electronic Health Record Definition and ONC Health IT Certification Program 

Modifications Final Rule.

9Department of Health and Human Services, Prescription Drug Monitoring Program 

Interoperability Standards, A Report to Congress (September 2013).

10Pub. L. No. 113-66, Div. A, Title VII, § 713, 127 Stat. 672, 794-798 (Dec. 26, 2013).

11Gartner, Gartner’s Update to the Enterprise Electronic Health Record Generation Model, 

(August 2016). Gartner uses a generation model to track the progression in capabilities of 

electronic health record systems evolving from very simple systems that provide results 

reporting to complex, fully integrated systems that clinicians can use to help facilitate the 

practice of evidence-based medicine. Gartner first introduced a five-stage enterprise 

electronic health record generation model in 1998, which was updated in 2007 and 

recently in 2016.

12The National Council for Prescription Drug Programs’ Script standard version 10.6 

specifies the standard for providers to use when sending a prescription electronically to a 

pharmacy.

13American Society of Health-System Pharmacists, Policy Positions 2009-2015 (with 

Rationales): Automation and IT.

14A. K. Ali, “Inventory Management in Pharmacy Practice: A Review of Literature” 

Archives of Pharmacy Practice. Vol. 2 Issue 4 (2011).
Appendix I: Objectives, Scope, and 

Methodology

Page 43 GAO-17-179 VA Pharmacy IT

From these sources, we compiled a list of practices that the health care 

industry has identified as being relevant to the implementation of an 

effective pharmacy IT system and that reflect areas of relevance with 

regard to VA’s health information system capabilities. This action resulted 

in a list of six practices that relate to (1) ordering medication 

electronically, (2) receiving drug order checks, (3) tracking the dispensing 

of controlled prescription drugs, (4) electronically exchanging 

prescriptions, (5) using clinical decision support capabilities, and (6) using 

a perpetual inventory management capability to monitor medication 

inventory levels.

We confirmed the validity and relevance of the identified practices with 

the Office of the National Coordinator for Health Information Technology. 

We also confirmed our selection of the practices through discussions with 

industry leaders, and based on the views and experiences of these 

sources, we characterized the practices that we assessed in the third 

objective as industry practices (rather than as best practices).

In addition, we reviewed the pharmacy system architecture and user 

documents, a VA Office of Inspector General Report on Pharmacy Reengineering,15 and VA’s plans to implement pharmacy system capabilities 

through its Pharmacy Re-engineering project and plans to modernize its 

Veterans Health Information Systems and Technology Architecture 

(VistA), such as the VistA 4 Roadmap. We compared the industry 

practices to current VA system capabilities and modernization plans to 

identify additional practices VA could implement to enhance its pharmacy 

IT system to be more aligned with those of the industry.

We supplemented our analyses with interviews of VA, DOD, and 

Department of Health and Human Services officials with knowledge of 

VA’s pharmacy systems and the interoperability efforts within VA and 

between VA and DOD. VA officials included those in the department’s 

Office of Information and Technology, VHA, and its Pharmacy Benefits 

Management Services, and the VA National Center for Patient Safety and 

Informatics Patient Safety. We also interviewed officials from the 

Department of Health and Human Services’ Office of the National 

Coordinator for Health Information Technology, as well as DOD officials 

 15Department of Veterans Affairs Office of Inspector General, Audit of the Pharmacy 

Reengineering Software Development Project (12-04536-308),(Dec. 23, 2013).
Appendix I: Objectives, Scope, and 

Methodology

Page 44 GAO-17-179 VA Pharmacy IT

from the Defense Health Agency and DOD/VA Program Coordination 

Office.

We conducted this performance audit from January 2016 to June 2017 in 

accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that 

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives.
Appendix II: Department of Veterans Affairs 

Pharmacy Related Applications

Page 45 GAO-17-179 VA Pharmacy IT

To enable the provision of health care services to veterans, the 

Department of Veterans Affairs (VA) uses its integrated health information 

system—the Veterans Health Information Systems and Technology 

Architecture (VistA)—which was developed in-house by VA clinicians and 

information technology (IT) personnel. The system consists of 

approximately 200 separate computer applications and modules, 17 of 

which include pharmacy related applications. The following table 

describes VistA applications categorized as pharmacy applications.

Table 1: Veterans Health Information Systems and Technology Architecture (VistA) Applications Used for Pharmacy

Application name Description

Automatic Replenish/Ward Stock Provides a method for the Department of Veterans Affairs (VA) medical 

centers to track drug distribution and inventory management within a 

medical center. 

Bar Code Medication Administration Validates patient identity and medication when clinicians administer unit 

doses and intravenous medications to inpatients at medical centers. 

Bar Code Medication Administration Backup Utility Interfaces with the VistA application to provide a real-time backup of all 

inpatient medication orders.

Consolidated Mail Outpatient Pharmacy Provides the capability for medical facilities to electronically submit 

prescriptions to a regional facility for mailing to patients. 

Controlled Substances Provides functionality for pharmacies to monitor and track the receipt, 

inventory, and dispensing of controlled substances. 

Data Management Provides tools for creating pharmacy orderable items and maintaining 

files necessary for the Computerized Patient Record System (CPRS), 

and for managing pharmacy software products, including Outpatient 

Pharmacy and Inpatient Medications. 

Drug Accountability/Inventory Interface Provides inventory functionality for each VA medical facility pharmacy to 

update and report on drug procurement history and inventories. 

Electronic Claims Management Engine Provides insurance companies the ability to create and distribute 

electronic outpatient pharmacy claims on behalf of pharmacy 

prescription beneficiaries in a real-time environment.

Inpatient Medications Integrates functions from intravenous and unit dose applications to 

provide clinicians with a comprehensive record of medications used 

during hospitalization of the veteran.

Inpatient Medications’ Intravenous module Provides pharmacists and their staffs with intravenous labels, 

manufacturing worksheets, ward lists for order updates, and 

management reports. It also enables pharmacy staff to track the 

preparation of intravenous formulas. 

Inpatient Medications’ Unit Dose module Provides inpatient caregivers a standard computerized system for 

dispensing and managing inpatient medications.

National Drug File Provides standardization of the local drug files in all medical facilities. 

Standardized drug information is key to comparing medication 

prescribed at different medical facilities, which supports clinicians and 

pharmacists in sharing prescription information with other facilities. 

Appendix II: Department of Veterans Affairs 

Pharmacy Related Applications
Appendix II: Department of Veterans Affairs 

Pharmacy Related Applications

Page 46 GAO-17-179 VA Pharmacy IT

Application name Description

Outpatient Pharmacy Provides pharmacists a method for dispensing and managing the 

medications given to veterans who have visited a clinic or who have 

received prescriptions upon discharge from the hospital. 

Medication Order Check Healthcare Application Performs drug-to-drug interactions, duplicate therapy order, and dosing 

order checks for Outpatient Pharmacy, Inpatient Medication, and CPRS 

VistA modules.

Pharmacy Enterprise Customization System Allows users to customize data used in the Medication Order Check 

Healthcare Application to perform prescription checks on the drug-todrug Interaction, drug pair, duplicate therapy, and dose range. 

Pharmacy Benefits Management Extracts medication dispensing data elements from VA medical centers 

to provide medical center leadership with projections of local drug usage 

and identification of potential accountability problem areas. 

Pharmacy Product System—National Registries Allows Pharmacy Benefits Management Services officials, at a national 

level, to specify medications that are to be purchased and used by the 

VA hospital system.

Source: GAO analysis of VA data. | GAO-17-179
Appendix III: Department of Veterans Affairs 

and Department of Defense Interoperability 

Initiatives

Page 47 GAO-17-179 VA Pharmacy IT

The following table describes the Department of Veterans Affairs (VA) 

and the Department of Defense’s (DOD) initiatives to share patient data, 

the pharmacy data exchanged, limitations, and plans for 

decommissioning.

Table 2: Department of Veterans Affairs (VA) and Department of Defense (DOD) Sharing Initiatives for Pharmacy Data

Initiative Description

Pharmacy

data exchanged Limitations

Planned upgrades

or decommission

Bidirectional Health 

Information Exchange 

Established in 2004, this 

data exchange was aimed at 

allowing clinicians at both 

departments viewable 

access to records on shared 

patients (that is, those who 

receive care from both 

departments, such as 

veterans who receive 

outpatient care from VA 

clinicians and then are 

hospitalized at a DOD 

treatment facility).

Outpatient pharmacy 

data

Drug and food allergy 

information

Inpatient 

documentation 

Data is read only 

and is not 

computable.

As of March 2017, this 

initiative is planned to be 

decommissioned by July 

2017.

Clinical Data 

Repository/Health Data 

Repository

The Clinical Data 

Repository/Health Data 

Repository interface links 

VA’s Health Data Repository 

and DOD’s Clinical Data 

Repository standardized 

data to enable a two-way 

exchange of computable 

outpatient pharmacy and 

medication allergy 

information.

Outpatient pharmacy

Drug allergy

Users must be 

marked as active 

dual consumers for 

data sharing.

VA has transition plans for 

the Clinical Data 

Repository/Health Data 

Repository with options for 

possible decommissioning. 

Specific plans for the 

Clinical Data 

Repository/Health Data 

Repository are dependent 

on future VA electronic 

health record 

modernization plans.

Joint Legacy Viewer Provides real-time, 

integrated, categorized, and 

chronological view of 

electronic health record 

information contained in 

existing DOD and VA 

systems.

Inpatient and outpatient 

medications

Allergies

Although data is 

computable, it is 

used in the Joint 

Legacy Viewer to 

view patient data

only.

VA will continue to support 

the Joint Legacy Viewer 

until clinical care can be 

aligned for a single viewer.

Source: GAO analysis of VA data. | GAO-17-179

Appendix III: Department of Veterans Affairs 

and Department of Defense Interoperability 

Initiatives
Appendix IV: Comments from the Department 

of Veterans Affairs

Page 48 GAO-17-179 VA Pharmacy IT

Appendix IV: Comments from the 

Department of Veterans Affairs
Appendix IV: Comments from the Department 

of Veterans Affairs

Page 49 GAO-17-179 VA Pharmacy IT
Appendix IV: Comments from the Department 

of Veterans Affairs

Page 50 GAO-17-179 VA Pharmacy IT
Appendix IV: Comments from the Department 

of Veterans Affairs

Page 51 GAO-17-179 VA Pharmacy IT
Appendix IV: Comments from the Department 

of Veterans Affairs

Page 52 GAO-17-179 VA Pharmacy IT
Appendix IV: Comments from the Department 

of Veterans Affairs

Page 53 GAO-17-179 VA Pharmacy IT
Appendix V: GAO Contact and Staff 

Acknowledgments

Page 54 GAO-17-179 VA Pharmacy IT

Valerie C. Melvin, (202) 512-6304, or melvinv@gao.gov

In addition to the contact named above, Tammi Kalugdan (Assistant 

Director), Daniel Wexler (Analyst in Charge), Nabajyoti Barkakati, 

Jennifer Beddor, Christopher Businsky, Debra Conner, Rebecca Eyler, 

Wilfred Holloway, Anh Le, Carlo Mozo, Monica Perez-Nelson, Martin 

Skorczynski, and Merry Woo made key contributions to this report.

Appendix V: GAO Contact and Staff 

Acknowledgments

GAO Contact

Staff 

Acknowledgments

(100555)
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