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. 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. 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. 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.