VA and Defense Health Care: Increased Risk of Medication Errors for Shared Patients
Published: 2002-09-27T00:00:00

Fast Facts:

Highlights:
section_title: What GAO Found
paragraphs: Medication errors and adverse drug reactions are a significant concern for the Department of Veterans Affairs (VA) and the Department of Defense (DOD) because their large beneficiary populations receive many prescriptions. Each agency has taken steps to reduce the risk of medication errors, such as making patients' medical records more accessible to providers and performing checks for drug interactions. Although each agency has designed safeguards to protect its own patients, some VA and DOD patients receive medication from both agencies. Shared patients face a higher risk of medication error. Joint (DOD and VA) venture sites with inpatient facilities provide services to shared inpatients in the same manner as they do for their own beneficiaries; that is, medications are ordered using the facility's guidelines and filled through the inpatient pharmacy at that facility. Gaps in safeguards result primarily from VA's and DOD's separate, uncoordinated information and formulary systems. Joint venture sites have tried to address some of these safety gaps. For instance, all sites have made patient information more accessible by providing additional, although incomplete, access to the other agency's patient information system.

section_title: Letter
paragraphs: Adverse drug events (ADE), which include adverse drug reactions and  preventable medication errors, have gained national attention in recent  years. The risk of medication errors is an important issue for the  Department of Veterans Affairs (VA) and the Department of Defense  (DOD), in part because their large beneficiary populations receive many  prescriptions—in fiscal year 2000, 86 million and 66 million, respectively.  Each agency has recognized the significance of medication errors and has  instituted practices to reduce them, such as making patients’ medical  records more accessible to providers and performing checks for drug  interactions. Although each agency designed safeguards to protect its own  patients, certain VA and DOD patients receive medications from both  agencies—either because they are eligible for care under both systems or  because they are referred from one agency to the other under VA-DOD  health resources sharing agreements. Preventing medication errors for  these shared patients presents an additional challenge.
VA and DOD estimate that about 800,000 beneficiaries are dually eligible  for care from VA and DOD and an unknown number of additional  beneficiaries receive care through sharing agreements. Concerned about  the effectiveness of medication safeguards for shared patients, you asked  us to determine (1) from which agency shared patients obtain  medications, (2) whether gaps exist in medication safeguards for shared  patients, and (3) if gaps exist, how they are being addressed.
To conduct our work, we reviewed VA’s and DOD’s processes for  providing outpatient and inpatient medications to shared patients. To  focus our review on locations with large numbers of shared patients, we  examined VA and DOD’s seven joint ventures, which have had experience  working together under sharing agreements. At your request, we  conducted an on-site review of pharmacy operations at the joint venture in  Hawaii, where there is an agreement between Tripler Army Medical Center  and the VA Medical and Regional Office Center. At this site, we observed  how medications are provided to shared patients and evaluated these  processes for gaps in medication safeguards. We also examined  medication error reports and interviewed VA and DOD providers,  pharmacists, patient safety personnel, and information systems personnel.  We spoke by telephone with personnel in similar positions at the six other  joint venture sites to identify procedures used to provide medications to  shared patients and evaluated these procedures for medication safety  gaps. We spoke with personnel at all joint venture sites about their  medication safety programs, but we were not able to identify errors  specific to shared patients because neither VA nor DOD tracks information  in this way.
We also spoke with VA and DOD headquarters personnel knowledgeable  about pharmacy, patient safety, formulary, and information technology  issues. In addition, we reviewed the literature on medication errors and  consulted experts on patient safety and medication errors from the Joint  Commission on Accreditation of Healthcare Organizations (JCAHO); the  Institute for Safe Medication Practices (ISMP); and the Leapfrog Group for  Patient Safety, a coalition of more than 100 public and private  organizations that provide health care benefits. We conducted our work  from February 2002 through September 2002 in accordance with generally  accepted government auditing standards.
subsections: section_title: Background
paragraphs: To encourage the sharing of federal health care resources, the Veterans  Administration and Department of Defense Health Resources Sharing and  Emergency Operations Act authorizes VA medical centers and DOD  military treatment facilities (MTF) to enter into sharing agreements to buy,  sell, and barter medical and support services. Local VA and DOD officials  have identified benefits that have resulted from such sharing, including  increased revenue, enhanced staff proficiency, fuller utilization of staff  and equipment, improved beneficiary access, and reduced cost of  services.
Seven of these sharing agreements are joint venture agreements, which  involve the sharing of physical space as well as health care services. These  joint ventures range from a single, jointly staffed MTF serving both VA and  DOD patients—as is the case with Mike O’Callaghan Federal Hospital at  Nellis Air Force Base in Nevada—to more modest sharing in Key West,  Florida, where VA and DOD share a building that houses their separate  outpatient clinics. In addition to physical space, agreements at these sites  usually provide for one agency to refer patients to the other for inpatient  and/or outpatient care. As table 1 shows, DOD is most often the host  agency, that is, the agency providing the majority of services.
In addition to referred patients, joint ventures, like other VA and DOD  facilities, share dually eligible patients. Recent changes in VA’s and DOD’s  health care programs have increased both the number of dual eligibles and  the likelihood that they will obtain services from both systems. The  number of veterans, including all military retirees, eligible for VA health  care was increased in fiscal year 1999 due to removal of statutory  restrictions. In addition, the number of military retirees eligible for DOD  health care increased in 2001 when full eligibility was extended to retirees  age 65 and over. Furthermore, a February 2002 increase in VA’s  copayment for outpatient drugs—from $2 per prescription to $7 per  prescription—has given dual eligibles who receive health care from VA  more incentive to have their prescriptions filled at a DOD pharmacy.
subsections: section_title: Medication Errors Pose Significant Risk
paragraphs: The Institute of Medicine (IOM) raised national awareness of the problem  of medication errors with its 2000 study, To Err is Human: Building a  Safer Health System. As we reported in 2000, there is general agreement  that medication errors are a significant problem, although the actual  magnitude of the problem is uncertain. Researchers and patient safety  advocates have suggested certain measures to reduce the risk of  medication errors, and VA and DOD have incorporated many of these  measures as features of their health care systems. Figure 1 illustrates the  typical process, including safeguards that VA and DOD use to provide  medications to patients.
Medication safety experts have identified the following factors that can  contribute to reducing medication errors.
subsections: section_title: Accessible Patient Medical Information
paragraphs: According to experts from organizations such as the American Society of  Health-System Pharmacists (ASHP) and IOM, access to patient medical  information is important to both providers and pharmacists in reducing  medication errors. A study of adverse drug events conducted by Brigham  and Women’s Hospital found that the inaccessibility of patient  information—such as information on the patient’s condition, results of  laboratory tests, and current medications—was a leading cause of  prescribing errors. The ASHP guidelines for preventing hospital  medication errors state that prescribers should evaluate the patient’s total  status and review all existing drug therapy before prescribing new or  additional medications. They also recommend that pharmacists and others  responsible for processing drug orders should have routine access to  appropriate clinical patient information—including medication and allergy  profiles, diagnoses, and laboratory results—to help evaluate the  appropriateness and efficacy of medication orders. One way to provide  this ready access is a computerized medical record. A computerized  medical record can improve health care delivery by providing medical  personnel with better data access, faster data retrieval, and more  versatility in data display than available with a paper record.
Both VA and DOD are in the process of transitioning from paper-based to  electronic systems for recording and accessing patient health information.  VA’s system, the Computerized Patient Record System (CPRS), captures a  wide range of patient information, including progress notes, vital statistics,  laboratory results, medications, drug allergies, and radiological and  catheterization images. DOD’s system, the Composite Health Care System  (CHCS), captures similar, but less extensive, patient information. For  example, CHCS cannot capture or store progress notes or electronic  images.
section_title: Formulary Systems
paragraphs: JCAHO standards for hospitals and ambulatory health organizations  require that organizations maintain formularies and direct that they must  consider the potential for medication errors as a criterion for selecting  drugs that will be stocked. Although frequently considered a mechanism  for controlling costs, patient safety experts maintain that formulary  systems can also optimize therapeutic outcomes and facilitate medication  safety. According to IOM, a formulary system can help reduce adverse  drug events because the drugs selected for the formulary are evaluated by  knowledgeable experts and chosen based on their relative therapeutic  merits and safety. In addition, formularies limit unneeded variety in drug  use—a practice supported by ISMP and the Institute for Healthcare  Improvement—and assist in educating prescribers on safe and appropriate  use of formulary drugs.
Both VA and DOD have formulary systems. VA’s national formulary  consists of about 1,200 pharmacy items, including over 1,000 drugs, and  each of VA’s 21 regional Veterans Integrated Service Networks can  augment the national formulary. DOD’s Basic Core Formulary consists of  about 165 drugs, and an MTF can add other drugs based on the clinical  services and scope of care provided by that facility. Both agencies also  have approval processes for prescribers to obtain nonformulary drugs for  their patients when medically necessary. As part of their ordering systems,  some VA and DOD facilities have also developed electronic decision- making support related to their formularies, such as prompts to remind  physicians to order specific laboratory tests prior to administering certain  drugs or alerts related to the safe use of certain drugs.
section_title: Computerized Provider Order Entry
paragraphs: CPOE systems can reduce medication errors by eliminating legibility  problems of handwritten orders and providing clinical decision-making  support by sending alerts and instantaneous reminders directly to  providers as orders are being placed. For instance, as providers enter a  medication order, they can be given a potential range of doses for  medications ordered, alerted to relevant laboratory results, and prompted  to verify which medication is being ordered when the drug sounds or  looks like another drug on the formulary. Studies have shown  computerized provider ordering reduced medication errors by 55 percent  to 86 percent. In light of this evidence, the Leapfrog Group for Patient  Safety adopted computerized provider order entry as one of its initial  safety standards. ISMP has also emphasized the need to take advantage of  electronic ordering technology, calling for the elimination of handwritten  prescriptions nationwide by 2003.
VA and DOD acknowledge the safety benefits of providers electronically  ordering medications, and both CPRS and CHCS (for outpatient  prescriptions only at most locations) have this capability. VA established  a goal in its 2002 Network Performance Plan for 95 percent use of CPOE  (both inpatient and outpatient) by 2002, with 100 percent use planned for  2004. While DOD officials told us that CPOE is encouraged and widely  utilized, DOD has no written policy or goals related to its use.
section_title: Automatic Checks for Drug Interactions and Allergies
paragraphs: Both VA’s and DOD’s electronic ordering systems perform automatic  checks for potential adverse reactions due to drug allergies and  interactions. VA’s CPRS performs checks for drug allergies and  interactions between all medications ordered and dispensed by a VA  facility, including those sent from VA’s mail order center. Although  medications dispensed for the same patient at another VA facility are  generally not included in the check, VA officials told us that they are  exploring methods to broaden their drug interaction capability. DOD’s  system for drug interaction checking is more comprehensive than VA’s  system. CHCS checks for drug allergies and interactions between drugs  prescribed or dispensed at the MTF, and DOD’s Pharmacy Data  Transaction Service (PDTS) aggregates information from CHCS with other  points of service—other MTFs, network pharmacies, and DOD’s mail  order pharmacy—to perform a complete drug interaction check.
Automatic electronic checks for drug interactions, commonly available in  retail drug stores, have been shown to greatly minimize medication  errors. For example, one study found that an automated review of  prescriptions written for 23,269 elderly patients produced 43,007 alerts  warning about potential medication problems—24,266 of which  recommended a change in drug or dosage. Professional groups such as  ASHP and ISMP have also acknowledged the value of these systems.
section_title: Shared Patients Obtain Inpatient Drugs from the Treating Agency but Generally Return to Home Agency for Outpatient Drugs
paragraphs: At the six joint venture sites where inpatient services are provided, all  patients referred for inpatient care receive medications from the inpatient  facility providing the care. Processes used to provide and record  inpatient medications to referred patients are the same as those used for  the host agency’s own beneficiaries. Inpatient medications are ordered  using the host facility’s formulary guidelines and filled through the  inpatient pharmacy. Initial supplies of discharge medications (usually 30  days or less) are also typically provided, although patients are expected to  return to their home agency pharmacy for longer-term supplies.
In contrast, the process for providing medications to shared outpatients  differs across sites. At six of the joint venture sites, each agency maintains  a separate outpatient pharmacy. As a general rule, each agency expects its  beneficiaries to use its pharmacy for outpatient prescriptions, even when  providers from the other agency order the prescription. For instance, in  Hawaii, both the Tripler Army Medical Center and the VA outpatient clinic  next door maintain outpatient pharmacies. VA patients who are referred to  Tripler for outpatient specialty care are expected to return to the VA clinic  pharmacy to have their prescriptions filled. Even though this is the general  rule at most sites, we noted that exceptions occur. For instance, at David  Grant Medical Center on Travis Air Force Base, DOD supplies oncology  medications to VA patients. Another exception is that all joint venture  inpatient facilities provide weekend and after-hours emergency room care  to patients of the other agency and, generally, medications are also  supplied if needed. In contrast to the general rule, at the DOD facility in El  Paso, referred VA patients are not expected to return to their home agency  for their initial prescriptions but rather are allowed to obtain an initial  supply of drugs from the DOD pharmacy. Subsequent prescriptions for  these patients (renewals or refills) must be filled by their VA pharmacy.
At the seventh site, Key West, only DOD maintains a pharmacy. It serves  both VA and DOD patients. However, VA patients receive only initial,  short-term prescriptions (up to 30 days) from this DOD pharmacy and  obtain longer-term prescriptions and refills via mail from the VA Medical  Center in Miami.
section_title: Shared Patients Experience Gaps in Medication Safety Measures
paragraphs: VA’s and DOD’s separate, uncoordinated information and formulary  systems result in gaps in medication safeguards for shared inpatients and  outpatients. Lacking coordinated information systems, providers and  pharmacists at joint venture sites often cannot access shared patients’  complete health information, including prescribed medications, nor can  providers from one agency use electronic ordering to prescribe drugs that  are to be dispensed by the other agency’s pharmacy. Because information  systems are uncoordinated, checks for drug allergies and interactions for  shared patients are based on incomplete information. In addition, separate  formulary systems introduce complications for shared patients because  providers must either prescribe from the other agency’s formulary, which  may contain drugs unfamiliar to providers, or prescribe a limited supply of  a drug, which may later be switched to comply with the formulary of the  patient’s home agency. These gaps are illustrated in figure 2.
subsections: section_title: Providers and Pharmacists Have Incomplete Access to Health and Medication Information on Shared Patients
paragraphs: Ready access to pertinent clinical information is an important feature of  medication safety; while VA’s and DOD’s patient information systems are  capable of serving this function for each agency’s own beneficiaries, gaps  exist for shared patients. VA and DOD providers and pharmacists have  ready access to health records of their own beneficiaries, largely through  CPRS and CHCS, respectively. However, when agencies refer patients for  care, the treating agency’s providers and pharmacists have incomplete  access to patients’ health and medication information. Although referrals  will usually be accompanied by some explanation of patients’ medical  conditions, the bulk of their electronic health and medication information,  which resides in the health information system of their home agency, will  often not be available to providers and pharmacists in the agency where  they are referred for care. Access for pharmacists and treating providers to  patient information in the referring agency’s information system varies by  location. For example, at four joint venture sites, pharmacists filling  prescriptions for shared patients have no access to the other agency’s  patient information system. At another site, pharmacy access is  restricted—at Tripler Army Medical Center in Hawaii, access to VA’s CPRS  is available in the inpatient pharmacy, but only one pharmacist has access.  Providers at a few facilities have broader access. For example, at the  David Grant Medical Center at Travis Air Force Base in northern  California, CPRS is installed on every network computer that has CHCS,  and providers in certain departments have been granted CPRS access.
VA and DOD pharmacists and providers we spoke with noted that lack of  relevant patient health information could be a problem for shared patients.  One example given to us was a VA provider treating a dual-eligible patient  for diabetes. Certain drugs cannot be safely prescribed for diabetics  without monitoring through laboratory tests. If the patient receives care  from a VA physician but has prescriptions filled at a DOD pharmacy, the  pharmacist would be unable to access the patient’s medical record to  review these laboratory results. Without this access, the pharmacist must  call VA to ensure these laboratory values are within normal limits. In  addition, pharmacy personnel at Tripler in Hawaii, where a single inpatient  pharmacist has CPRS access, told us that additional pharmacists need  CPRS access to facilitate after-hours medication needs of VA patients  when this pharmacist is unavailable.
section_title: Providers Generally Cannot Electronically Prescribe Drugs for Shared Patients
paragraphs: Computerized provider ordering of medications increases safety by  assisting with medication decisions, providing alerts for drug interactions  and allergies, and obviating handwriting legibility and transcription  problems. However, prescriptions for shared patients are less likely to be  ordered electronically by providers. Although both VA and DOD providers  have outpatient electronic ordering capabilities when prescriptions are  dispensed at their own pharmacies, patients referred from one agency to  the other for care are typically expected to return to their home pharmacy  to get prescriptions filled. With the exception of DOD providers in  Hawaii, none of the joint venture sites have the capability for providers to  electronically order medications through their own computer systems for  drugs that are to be dispensed by the other agency’s pharmacy, nor do  they typically have access to the other agency’s electronic ordering  systems to issue medication orders. Consequently, providers either  handwrite medication orders for shared patients or give them printed  copies that must be retyped into the patients’ home agency’s pharmacy  system. Both situations introduce risks unique to shared patients.
We also found situations where providers had the capability to avoid  handwriting prescriptions but continued to handwrite them. In Key West,  for example, where all drugs are dispensed from the DOD pharmacy, VA  providers have access to DOD’s electronic ordering system, CHCS; but, for  the most part, they handwrite prescriptions. These providers record  patient care and medications in VA’s CPRS, and if they were to  electronically order medications, it would necessitate entry into a second  system. They told us that using CHCS was slow and cumbersome, and  ordering the medications using it took too much time. A VA provider in  Hawaii told us that, for these same reasons, providers sometimes  handwrote prescriptions for dual eligibles to have filled at the DOD  pharmacy when only one or two medications were being ordered.
Finally, although VA patients benefit when providers electronically order  medications in VA hospitals, they generally lose this benefit when referred  to DOD hospitals. Providers in VA hospitals have electronic ordering  capability for inpatient medications, but this capability is not generally  available in DOD hospitals. VA patients referred to DOD hospitals, like  DOD’s own beneficiaries, usually have their prescriptions handwritten by  the provider, and then manually entered into CHCS by pharmacy  personnel. Thus, these patients are subjected to the risks associated with  handwritten prescriptions, such as illegible orders and transcription  errors.
section_title: Incomplete Record of Patient Medications Hinders Automatic Checks for Drug Interactions and Allergies
paragraphs: Shared patients also do not get the full benefit of VA’s and DOD’s  automatic checks for drug allergies and interactions. VA and DOD patients  who receive all their medications through only one health care system will  have comprehensive medication histories stored in either CPRS or CHCS  (in conjunction with PDTS). When the medication is ordered, CPRS or  CHCS/PDTS will perform automatic checks for drug allergies and  interactions. However, if patients are taking medications obtained from  both agencies, neither agency’s record of patient medications is complete  at any joint venture site. Thus, when interaction checks are done, they will  be incomplete for shared patients because the checks are restricted to the  information available within each system. Likewise, providers may be  unaware of drug allergies. For example, when a patient who routinely gets  health care at the VA clinic in El Paso is referred to the Army Medical  Center for outpatient specialty care, the DOD pharmacy will fill a  prescription for up to 30 days of medications. However, when the  pharmacy performs its automatic checks, drug allergies may not be  detected because information on drug allergies is likely to be in VA’s CPRS  where the bulk of the patient’s clinical information is stored, not in  CHCS/PDTS where the drug check will occur. In its interim report, the  President’s Task Force to Improve Health Care Delivery for Our Nation’s  Veterans stated that the instances of adverse drug events might be  substantially reduced for shared patients through use of a comprehensive  screening tool like PDTS and plans further analysis in this area for its final  report.
section_title: Uncoordinated Formulary Systems Also Introduce Risks
paragraphs: Because VA and DOD each has its own formulary system, providers who  treat referred patients sometimes prescribe from the referring agency’s  formulary and sometimes from their own facility’s formulary, depending  on where the prescription will be filled. Unless the prescribed drug is  common to both formularies, each situation limits the medication safety  benefits of a formulary system, such as increased provider familiarity with  drugs prescribed and the added safety net provided by clinical decision  support. The President’s Task Force to Improve Health Care Delivery for  Our Nation’s Veterans noted that a joint VA/DOD formulary could combine  the clinical expertise of both VA and DOD and improve patient safety.
Providers who use the other agency’s formulary in prescribing for shared  patients and find that the drug they would normally prescribe is not listed  are disadvantaged in several ways. First, according to formulary system  principles endorsed by the American Medical Association, ASHP, and  others, one characteristic of a formulary system should be that the  pharmacy and therapeutics committee educates providers about drugs on  the formulary. A senior official from ISMP told us that provider drug  knowledge is also reinforced by a formulary system because formularies  limit the number of drugs providers need to be knowledgeable about.  Consequently, providers should be less likely to make mistakes in drug  selection or dosage when prescribing formulary drugs. Second, when  prescribing a drug that is not on their formulary, providers may lose the  clinical support capabilities that may be built into their agency’s CPOE  system. For example, the medication error prevention committee at  Tripler in Hawaii evaluates Tripler’s formulary drugs for safety problems  and designs safeguards into CHCS, such as distinctive lettering to alert  providers to drug names that look alike or sound alike. However, DOD  providers typically try to prescribe for VA outpatients using VA’s  formulary. Consequently, this safeguard is lost to the shared patient.
Providers usually prescribe from their own facility’s formulary for a  referred patient if the prescription is to be filled at their facility’s  pharmacy. For instance, at all joint venture sites, referred inpatients  receive short-term supplies of discharge medications at the host facility’s  pharmacy. If patients need longer-term supplies of medications or refills,  they typically are expected to return to their home pharmacy. This  situation can also put patients at risk if the original medication is not on  the formulary at their home pharmacy. For instance, in Key West, VA  physicians write VA patients two different prescriptions: one for their  initial supply to be filled at the joint venture’s DOD pharmacy and a  second for a longer-term supply that is mailed from the VA Medical Center  in Miami. One VA physician told us that when a VA formulary drug he  wants to prescribe is not on the DOD formulary, he prescribes an  equivalent drug carried by the DOD pharmacy for the short term and  orders the VA formulary drug from Miami to use on a long-term basis.  Experts agree that such interchanging of drugs in a therapeutic class may  sometimes cause problems because differences in individual physiology  make some people react differently to a very similar therapeutic agent.  Although such interchange is an accepted practice in formulary systems,  when physicians are able to avoid switching drugs, they reduce the risk  that an adverse reaction will occur.
section_title: Safety Gaps Remain Despite Efforts to Address Them
paragraphs: Recognizing these risks for shared patients, joint venture facilities have  undertaken efforts intended to address these safety gaps. However, none  of these efforts fully solve the problems that exist, nor are they all used at  any site.
All joint venture sites have taken steps to increase access to patient  information. For example, at Tripler in Hawaii, VA and DOD recently  added VA’s CPRS to computers in the DOD hospital so that VA physicians  monitoring the care of VA inpatients would have electronic access to  patients’ VA health records. However, at the time of our visit, most DOD  physicians were unaware that the capability to access CPRS existed, and  DOD officials at Tripler had no plans to promote its use or to provide  training. Similarly, some physicians at all other joint ventures have access  to both systems; but, as in Hawaii, this access is generally limited in the  number of computers that have this capability and the number of  providers who have been authorized to use it. For instance, access to both  systems is available at some locations in the Mike O’Callaghan Federal  Hospital in Nevada, but VA pharmacy officials at the VA outpatient clinic  in this joint venture told us that the lack of such access in the clinic  presented a major problem. They told us that not having access to such  patient information as test results and physician notes made it difficult for  them to research questions about patients’ medications. Only two sites  have pharmacies with access to the other agency’s patient information  system; access is very limited at one of those sites—at Tripler, only one  pharmacist has been authorized to use CPRS. Furthermore, medical  personnel who had access told us that its use is hindered by their lack of  familiarity with the other agency’s system and by the difficulties of  accessing separate, dissimilar systems.
Recognizing the increased risks associated with handwriting prescriptions  rather than using CPOE, two joint venture sites have devised ways to  minimize this risk for shared patients. In Hawaii, VA providers have  worked out an agreement with the DOD pharmacy that they will provide  dual beneficiaries a computer-printed copy of the electronic order, called  an “action profile,” which the pharmacy will accept in lieu of a  handwritten order. In Hawaii—at the time of our visit—and northern  California, a printer for DOD’s CHCS had been installed in the VA  pharmacy so that medication orders from DOD providers could be printed  out in the VA pharmacy. VA pharmacy personnel then re-enter orders into  CPRS to dispense the medications. While these efforts remove the  potential for misreading handwritten prescriptions, they fall short of the  full benefits of electronic ordering and filling because re-entering  information into CPRS introduces the potential for transcription errors. In  August 2002, information technology personnel in Hawaii implemented an  electronic link that allows outpatient medication orders entered into  CHCS for VA patients to be transmitted directly into CPRS, eliminating the  need for manual re-entry in the VA pharmacy. Officials involved in the  Hawaii project told us that this link is working well and that this  technology was developed with the intent of transferring it to other sites.  They also told us that the project was developed with the ultimate intent  of two-way—or bi-directional—communications, so that with some  additional modification a link could be established allowing VA physicians  to send CPRS medication orders to CHCS at Tripler for processing and  filling.
Three joint venture sites have taken steps to compensate for problems  associated with drug interaction checks for shared patients. For example,  VA physicians in Hawaii told us that when they provide prescriptions for  dual eligibles to be filled at DOD’s pharmacy, they also enter them into  VA’s CPRS and mark them “hold” so that they will not be dispensed by the  VA pharmacy. Thus, checks for interactions with other drugs prescribed  by VA can be performed by CPRS, and the patients’ medication  information will be updated to reflect the medication orders. In Texas, VA  adds information to CPRS about care and medications provided to  referred patients by DOD physicians. This information is recorded in a  special section of CPRS. When VA physicians subsequently access  patients’ records, CPRS alerts them that new information has been added  to this section of the record, but the information is not included in  automatic drug checks. The VA clinic in Anchorage, Alaska, uses a  different approach to address the problem of incomplete medication  records. Officials there told us they have developed software to  supplement information in the CPRS record by capturing and displaying  information about drugs obtained from DOD and other non-VA sources,  including herbal supplements and over-the-counter drugs. Thus, providers  and pharmacists have additional information that might help them prevent  adverse drug interactions. However, information collected in this way may  not be accurate or complete because it depends on patient recall and is  entered manually. In addition, this information is not accessed by CPRS’s  automatic drug checks because it is a supplement to, not a part of, the  CPRS record.
Finally, five joint ventures have instituted practices to address safety  problems related to separate formularies. For example, the Mike  O’Callaghan Federal Hospital at Nellis Air Force Base in Nevada has a  combined P&T committee that includes both VA and DOD representatives  who select the medications that will be included on the hospital’s inpatient  formulary. In addition, the committee approved nearly 50 VA formulary  medications to be stocked in the hospital pharmacy for use by VA  inpatients at this facility. All measures taken to improve medication safety,  such as entering reminders or alerts into CHCS to safeguard against  medication mistakes, also apply to VA drugs stocked in the pharmacy.  Other sites have undertaken less comprehensive measures to address  problems arising from separate formularies. For instance, pharmacies at  two sites stock drugs commonly prescribed for the other agency’s  patients, but neither host agency’s P&T committee has representatives  from both agencies. At two other sites, representatives from both agencies  are on the host agency’s P&T committee. While these efforts are helpful in  overcoming difficulties associated with separate formularies, none is a  complete solution.
section_title: Conclusions
paragraphs: As VA and DOD strive to improve efficiency and access to care through  greater collaboration and sharing of resources, it is likely that the number  of patients who receive care from both systems will increase.  Consequently, the safety of shared patients merits continuing concern.  While our findings are based on the joint venture sites, they may have  relevance wherever patient care is shared between VA and DOD.
Some joint ventures have taken steps to address medication safety  problems for shared patients, but these steps are partial solutions and gaps  remain. For example, facilities have provided only limited access to the  other agency’s patient medical information system and have not always  provided training in its use. Therefore, providers do not have adequate  access to patient medical information for shared patients, and lacking the  comprehensive capability afforded by a system like PDTS, they can  perform only incomplete checks for drug interactions and allergies. In  addition, when shared patients return to their home agency to have  prescriptions filled, providers give them handwritten or computer-printed  prescriptions, rather than electronically ordering medications, creating  risk for legibility or transcription errors. Furthermore, separate P&T  committees may be unable to effectively overcome problems that arise  from separate formularies. The measures already taken by some joint  ventures show that risks that shared patients face can be addressed. VA  and DOD could develop systemwide rather than local solutions to address  the needs of shared patients nationally as well as at the joint venture sites.
section_title: Recommendations For Executive Action
paragraphs: To better protect shared patients at the joint ventures, we recommend that  the Secretary of Veterans Affairs direct the Under Secretary for Health and  that the Secretary of Defense direct the Assistant Secretary of Defense for  Health Affairs to    develop the capability for VA and DOD providers to access patient medical  information relevant to medication decision making, regardless of whether  that information resides in VA’s or DOD’s information system and provide  training to physicians and pharmacists who need to use this access;    develop the capability to perform a comprehensive, automatic drug  interaction check that uses medication information from all VA and DOD  facilities and mail order operations and DOD’s network pharmacies, and  evaluate the potential for DOD’s PDTS to be used for this purpose;  require providers to use computerized order entry of medications for  shared patients where it is available and implement system modifications  that will enable providers to electronically order medications to be  dispensed at the other agency’s pharmacies; and    establish a joint VA and DOD pharmacy and therapeutics committee, or  similar working group, at each joint venture site to determine how best to  safely meet the medication needs of VA and DOD shared patients and to  overcome obstacles associated with separate formularies.
section_title: Agency Comments and Our Evaluation
paragraphs: The Department of Veterans Affairs and the Department of Defense  provided written comments on a draft of this report. These comments are  discussed below and reprinted in appendix I and appendix II, respectively.  VA concurred with all our recommendations, while DOD concurred with  two of our recommendations, partially concurred with one, and did not  concur with one.
Both VA and DOD concurred with our recommendation to develop the  capability for VA and DOD providers to access patient medical information  in both CPRS and CHCS. In their comments, both agencies discussed  longer-term solutions, such as the joint VA-DOD Federal Health  Information Exchange (FHIE) initiative. While we support long-term  efforts that would lead toward a more seamless sharing of information  between VA and DOD, we believe that a number of joint venture sites have  demonstrated that interim steps, such as giving providers access to and  training on the other agency’s system, are both warranted and feasible.
Both agencies also concurred with our recommendation regarding the  development of comprehensive, automatic drug interaction checks,  including the evaluation of PDTS for this purpose. VA stated that this  capability would be accomplished with the second phase of the VA-DOD  joint plan, called HealthePeople (Federal), which VA expects to be  implemented in fiscal year 2005. Although agreeing to evaluate the cost  benefit of adopting PDTS, VA said that, based on VA and DOD workload  data, a relatively small number of veterans had been treated in both  systems in the period from October 2001 through May 2002 (240,716  unique patients, or 29.6 percent of all dual eligibles) and raised the issue of  whether the cost of PDTS was justified for so few cases. We believe this  almost quarter of a million patients represents a significant opportunity for  adverse drug events to occur, especially since, based on the prescription  patterns of a typical VA patient, this group received an estimated 4 million  prescriptions in this 8-month period. Furthermore, the number of patients  potentially at risk is larger than the dual eligible group. It includes an  unknown number of patients who receive care and medications from both  agencies under VA-DOD resource sharing agreements. While we agree that  cost is an important factor, we believe the large number of prescriptions  for these patients justifies an evaluation of PDTS that considers both cost  and patient safety.
VA concurred and DOD partially concurred with our recommendation on  CPOE. VA said it has already planned for its providers to use computerized  order entry for all orders, including medications, by fiscal year 2004. It also  made reference to the Hawaii pilot project discussed earlier in this report  as a way of extending this capability for shared patients but said that a  more robust bi-directional capability would be included as a systems  requirement in the HealthePeople (Federal) effort. DOD also agreed to  require that providers use CPOE for shared patients where available;  however, it did not agree with system modifications as the approach for  extending this capability. Instead, DOD advocated the joint procurement  of a commercial off-the-shelf pharmacy information system. It said that  this approach would provide greater economic returns and system  interoperability since both agencies are pursuing plans to upgrade or  replace their pharmacy information system modules. We agree with this  approach as a longer-term solution. However, agency officials told us that  neither agency has plans to upgrade or replace its system until fiscal year  2005 at the earliest, leaving shared patients at continued risk for  medication errors until the new system is operational. System  modifications already accomplished in Hawaii indicate that interim steps  toward reducing these risks are possible.
VA concurred with our recommendation on establishing a joint P&T  committee or similar working group at each joint venture site and said it  would pursue this recommendation via the VA/DOD Executive Committee,  a working group for VA/DOD collaboration issues. DOD did not concur  with establishing a joint P&T committee at each site; however, we  recommended the establishment of a joint VA-DOD group, either a P&T  committee or a similar working group, that would determine how best to  safely meet the medication needs of shared patients at each site. DOD  expressed support for the already-established working groups, but, as we  have noted, only three joint venture sites have such collaborative groups.
We are sending copies of this report to the Secretary of Veterans Affairs,  the Secretary of Defense, and other interested parties. Copies will also be  made available to others on request. In addition, the report is available at  no charge on the GAO Web site at http://www.gao.gov. If you or your staff   have any questions about this report, please contact me at (202) 512-7101.  Other contacts and major contributors are listed in appendix III.
section_title: Appendix I: Comments from the Department of Veterans Affairs
section_title: Appendix II: Comments from the Department of Defense
section_title: Appendix III: GAO Contacts and Staff Acknowledgments
subsections: section_title: GAO Contacts
section_title: Acknowledgments
paragraphs: In addition to those named above, the following staff members made key  contributions to this report: Irene J. Barnett, Linda Diggs, Mary W. Reich,  Karen Sloan, and Thomas Walke.