VA Information Technology: Pharmacy System Needs Additional Capabilities for Viewing, Exchanging, and Using Data to Better Serve Veterans
Published: 2017-06-14T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: 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.
section_title: What GAO Found
paragraphs: 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.
section_title: What GAO Recommends
paragraphs: 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.

section_title: Letter
paragraphs: 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   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  our designation of VA health care as a high-risk area for the federal  government.
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. 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. 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  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. 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, 2008, and 2014 National Defense  Authorization Acts. We observed clinicians’ and pharmacists’ use of VA  and DOD systems for the purposes of exchanging pharmacy data in real- time 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   Services’ Office of the National Coordinator for Health Information  Technology, the American Society of Health-System Pharmacists, the  Archives of Pharmacy Practice, and a private provider. We reviewed  the Office of the National Coordinator for Health Information Technology’s  certification criteria for health IT systems  and its advisory on  interoperability  standards. We also reviewed Gartner’s Update to the  Enterprise Electronic Health Record Generation Model, as well as  standards set by the National Council for Prescription Drug Programs.
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  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, a 2011 comparison of VA’s  electronic health record system to leading commercial solutions, 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.
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.
subsections: section_title: Background
paragraphs: VHA provides health care to approximately 6.7 million veterans and their  families at an estimated annual cost of about $56 billion. 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. 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. 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  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.
subsections: section_title: Veterans Health Information Systems and Technology Architecture and Its Pharmacy Applications
paragraphs: VHA relies on the department’s health information system—the Veterans  Health Information Systems and Technology Architecture (VistA)—to  deliver health care. 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. 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 Re- engineering 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  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.
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. 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  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 e- prescribing, a capability to receive inbound electronic prescriptions (e- prescriptions) from a non-VA provider, and then fill, and dispense the  prescriptions in VistA. From fiscal years 2002 to 2016, VA reported  spending about $187.6 million for the Pharmacy Re-engineering project.
Figure 2 shows a timeline of the modernization initiatives for the  Pharmacy Re-engineering project in relation to VA’s VistA 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  pharmacy services, it has responsibility for developing computer systems  based on requirements from Pharmacy Benefits Management Services.
section_title: DOD’s Armed Forces Health Longitudinal Technology Application and Pharmacy System
paragraphs: 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. 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.
section_title: Pharmacy IT System Industry Practices
paragraphs: 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  pharmacy IT systems stress the use of capabilities aimed at improving  the efficiency and effectiveness of clinicians and pharmacists in  prescribing and dispensing medication. Among others, these  capabilities would enable clinicians and pharmacists to:
Electronically order medications, and record, change, and access a  medication order for a patient. 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.
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. Clinical decision  support systems, such as drug interaction, allergy, and dose  monitoring warning systems, should be adopted to make patient care  more efficient and effective.
Track the dispensing of controlled prescription drugs to patients  through state-run prescription monitoring drug programs, 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.
Electronically create prescriptions for electronic transmission in  accordance with National Council for Prescription Drug Programs  standards. 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. Specifically, Gartner’s Generation Model  for Enterprise Electronic Health Record systems is a framework where  generation level 3 calls for establishing effective clinical decision   support capabilities, clinical workflow, clinical display, 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.
section_title: GAO and VA’s Inspector General Have Previously Reported on VA’s Pharmacy System Efforts
paragraphs: 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, but had not completed important steps for exchanging these  data for all shared patients. 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  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. 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.
section_title: VA Has Pharmacy System Capabilities, but Inefficiencies Exist in Viewing and Transferring Data
paragraphs: 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.
subsections: section_title: VA Has Pharmacy System Capabilities for Prescribing and Dispensing Medications, but Inefficiencies Exist in Viewing Pharmacy Data
paragraphs: 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. 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.
VA’s current pharmacy system capabilities are being provided by 17 VistA  pharmacy software applications  and CPRS which, collectively, enable  clinicians and pharmacists to process, view, and share pharmacy data.
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.
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.
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.
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  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.
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,  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; 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  department does not have plans to address this issue due to other re- engineering 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.
section_title: Pharmacists Cannot Transfer Prescriptions to Other VHA Pharmacies
paragraphs: 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. 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.
section_title: VA’s Pharmacy System Has Certain Interoperability Capabilities with DOD, but Limitations Reduce Effectiveness; VA Has Not Assessed the Impact of Interoperability
paragraphs: 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  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.
subsections: section_title: VA’s Pharmacy System Enables Interoperability Capabilities with DOD, but Clinicians and Pharmacists Cannot Always View Data or Receive Complete Order Checks
paragraphs: 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 mapped  their medication data to the national standard RxNorm, thereby enabling 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 real- time 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, 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, 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  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  always be performed for new medications that have not been mapped to  the national standards.
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).  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. 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.
section_title: VA Has Not Assessed the Impact of Pharmacy System Interoperability on Transitioning Service Members
paragraphs: According to the Office of Management and Budget guidelines, 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  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  pharmacy system to adequately support its mission of providing health  care to veterans.
section_title: VA’s Pharmacy System Incorporates Some Health Care Industry Practices, but Not Others
paragraphs: 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-to- drug 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 dose 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. According to Pharmacy Benefits  Management Services officials, and based on our visits to selected  medical sites, VA currently sends data on prescriptions for controlled substances to 47 state programs. 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.
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.
subsections: section_title: VA’s Pharmacy System Has Not Incorporated Three Practices That Could Enhance Its Usefulness
paragraphs: 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.
subsections: section_title: VA’s System Does Not Electronically Exchange Prescriptions with Non-VA Entities
paragraphs: 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. The Office of the National Coordinator for Health  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). 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 non- VA pharmacy.
According to the VistA 4 Roadmap, 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  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 non- VA 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.
section_title: VA’s System Does Not Include Certain Clinical Decision Support Capabilities; Plans for Implementation Are Incomplete
paragraphs: As previously discussed, Gartner’s Generation Model for Enterprise  Electronic Health Record systems  is a framework where generation  level 3 calls for establishing effective clinical decision support  capabilities, clinical workflow, and clinical display, 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,  and clinical workflow. 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.
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 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.
section_title: VA’s System Does Not Maintain a Perpetual Inventory to Monitor Medication Inventory Levels
paragraphs: 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. 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  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 Re- engineering 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.
section_title: Conclusions
paragraphs: 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  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.
section_title: Recommendations for Executive Action
paragraphs: 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; 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.
section_title: Agency Comments and Our Evaluation
paragraphs: 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.
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.
section_title: Appendix I: Objectives, Scope, and Methodology
paragraphs: 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. 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).
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. 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, 2008, and 2014 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.
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. We reviewed the Office of the National  Coordinator for Health Information Technology 2015 Edition Health  Information Technology Certification Criteria, 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. Further, we reviewed  the 2014 National Defense Authorization Act, Gartner’s Update to the  Enterprise Electronic Health Record Generation Model, standards set  by the National Council for Prescription Drug Programs, and  publications from the American Society of Health-System Pharmacists,  and the Archives of Pharmacy Practice.
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 Re- engineering, 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  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.
section_title: Appendix II: Department of Veterans Affairs Pharmacy Related Applications
paragraphs: 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.
section_title: Appendix III: Department of Veterans Affairs and Department of Defense Interoperability Initiatives
paragraphs: 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.
section_title: Appendix IV: Comments from the Department of Veterans Affairs
section_title: Appendix V: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: 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.