This is the accessible text file for GAO report number GAO-07-554R 
entitled 'DOD and VA Outpatient Pharmacy Data: Computable Data Are 
Exchanged for Some Shared Patients, but Additional Steps Could 
Facilitate Exchanging These Data for All Shared Patients' which was 
released on April 30, 2007. 

This text file was formatted by the U.S. Government Accountability 
Office (GAO) to be accessible to users with visual impairments, as part 
of a longer term project to improve GAO products' accessibility. Every 
attempt has been made to maintain the structural and data integrity of 
the original printed product. Accessibility features, such as text 
descriptions of tables, consecutively numbered footnotes placed at the 
end of the file, and the text of agency comment letters, are provided 
but may not exactly duplicate the presentation or format of the printed 
version. The portable document format (PDF) file is an exact electronic 
replica of the printed version. We welcome your feedback. Please E-mail 
your comments regarding the contents or accessibility features of this 
document to Webmaster@gao.gov. 

This is a work of the U.S. government and is not subject to copyright 
protection in the United States. It may be reproduced and distributed 
in its entirety without further permission from GAO. Because this work 
may contain copyrighted images or other material, permission from the 
copyright holder may be necessary if you wish to reproduce this 
material separately. 

April 30, 2007: 

The Honorable Ike Skelton: 
Chairman: 
The Honorable Duncan Hunter: 
Ranking Member: 
Committee on Armed Services: 
House of Representatives: 

The Honorable Vic Snyder: 
Chairman: 
The Honorable John M. McHugh: 
Ranking Member: 
Subcommittee on Military Personnel: 
Committee on Armed Services: 
House of Representatives: 

Subject:DOD and VA Outpatient Pharmacy Data: Computable Data Are 
Exchanged for Some Shared Patients, but Additional Steps Could 
Facilitate Exchanging These Data for All Shared Patients: 

Since 1998, the Department of Defense (DOD) and the Department of 
Veterans Affairs (VA) have been working to electronically exchange 
patient health data, including outpatient pharmacy data,[Footnote 1] 
across their electronic health information systems. Exchanging 
outpatient pharmacy data is important for DOD and VA because certain 
DOD and VA patients, known as shared patients, receive health care from 
both agencies. Clinicians' access to complete health information from 
both agencies' health information systems could assist clinicians in 
making more informed medical decisions and help prevent adverse 
medication reactions--which include detrimental or unintended reactions 
when multiple medications are taken together and allergic reactions to 
a medication. In March 2004, DOD and VA began collaborating on a long-
term initiative to make their outpatient pharmacy data computable. 
Computable data refer to data that are in a format that a computer 
application can act on: for example, to provide automatic checks for 
adverse medication reactions or to plot graphs of changes in vital 
signs such as blood pressure. 

In reporting on this initiative in the past, we have noted that the 
agencies have experienced delays in their efforts to begin exchanging 
computable outpatient pharmacy data.[Footnote 2] Concerned about DOD's 
and VA's progress in this effort, you asked us to examine the 
initiative that the agencies have under way to make their outpatient 
pharmacy data computable. In this report, we provide information on: 

 DOD's and VA's expectations of what the exchange of computable 
outpatient pharmacy data will provide in safeguards against adverse 
medication reactions for shared patients. 

 The status of DOD's and VA's initiative for attaining computable 
outpatient pharmacy data. 

To address the objectives, we analyzed documents and interviewed 
officials from DOD and VA about the agencies' efforts to exchange 
computable outpatient pharmacy data for shared patients. We also viewed 
a demonstration of DOD's and VA's exchange of computable outpatient 
pharmacy data in El Paso, Texas, where DOD and VA first exchanged these 
data for shared patients. We conducted our work from July 2006 through 
April 2007 in accordance with generally accepted government auditing 
standards. 

On April 3, 2007, we provided a briefing to your offices on the results 
of this work. The briefing slides, included as enclosure I, have been 
updated to include more current information. This report summarizes the 
information presented in the briefing and officially transmits our 
recommendations to the Secretary of Defense and the Secretary of 
Veterans Affairs. 

Results in Brief: 

DOD and VA expect the exchange of computable outpatient pharmacy data 
to provide each agency with seamless access to shared patients' 
medication histories and more complete electronic checks for adverse 
medication reactions. Officials expect information on outpatient 
medications dispensed by either agency's health care system to be 
stored in each agency's repository in the standardized vocabulary each 
agency uses, following translation from a standardized set of terms, 
which will allow either agency's electronic health information system 
to include the other agency's data in its automatic checks. According 
to DOD and VA officials, having pharmacy data from both DOD and VA, 
rather than data from a single agency, could reduce adverse medication 
reactions by providing more complete checks for shared patients. 

DOD and VA are exchanging computable outpatient pharmacy data for some 
shared patients, but have not completed steps important for exchanging 
these data for all shared patients. DOD and VA developed an electronic 
interface--Clinical Data Repository/Health Data Repository (CHDR)-- 
that links DOD's and VA's health data repositories and allows for the 
exchange of computable data between them. Before computable data can be 
exchanged, patients who use both DOD's and VA's health care systems 
must be identified as shared patients and then activated, which refers 
to shared patients being matched on certain identifiers--first name, 
last name, date of birth, Social Security Number--in both agencies' 
health information systems and established as "active" shared patients. 
DOD and VA have begun exchanging computable outpatient pharmacy data 
through CHDR for patients activated at seven locations as of March 
2007.[Footnote 3] In addition, DOD officials indicated that all 
117[Footnote 4] DOD sites in the continental United States, Alaska, and 
Hawaii will be able to activate shared patients by the end of June 
2007; VA indicated that all 128 VA sites will be able to activate 
shared patients by mid-September 2007. DOD and VA have been addressing 
three issues that hinder their ability to exchange computable 
outpatient pharmacy data for all shared patients. 

 DOD and VA officials have identified two problems that prevent them 
from activating some shared patients. In some cases, patient 
information does not match exactly on all identifiers. In addition, VA 
patients who were discharged from active duty before 1997 may not have 
a unique identification number that DOD assigns to its beneficiaries, 
and without this number, these patients cannot be activated. According 
to DOD and VA, the agencies are working to resolve these problems. DOD 
stated that in February 2007 it completed a software upgrade to help 
resolve problems with matching patients' identifying information. 
Similarly, VA officials told us that VA is developing a software 
upgrade, but could not provide a date for when its upgrade would be 
operational. In addition, DOD reported that it is working with a VA- 
provided list of patients who are receiving care from VA and were 
discharged from active duty before 1997. DOD reported that it will 
create unique identification numbers for these patients and anticipates 
this effort will be completed by the end of September 2007. 

 VA must expand to all its 128 sites the capability to automatically 
check DOD data that are exchanged through CHDR. VA officials said this 
capability was in place at 10 sites as of March 2007 and expect it to 
be in place at all VA sites by the end of July 2007. 

 While DOD and VA officials told us that guidelines for identifying 
shared patients would help sites determine which patients should be 
activated, the agencies have not established written guidelines, 
including criteria to define shared patients and procedures to identify 
shared patients, for all sites to use. DOD expects the guidelines to be 
completed by the end of June 2007. 

Until DOD and VA take additional steps to ensure all shared patients 
benefit from the exchange of computable pharmacy data, many shared 
patients will not receive the benefit of more complete automatic 
electronic checks for adverse medication reactions. To meet the 
timelines for resolving the three issues identified, it will be 
important for the agencies to make these efforts a priority, given 
previous delays in developing the capability to exchange computable 
data. 

To help ensure that all shared patients benefit from the exchange of 
computable outpatient pharmacy data, the Secretary of Defense and the 
Secretary of Veterans Affairs should expedite certain ongoing efforts. 
Specifically, we recommend that (1) the Secretary of Defense and the 
Secretary of Veterans Affairs expedite efforts to develop a solution 
for activating shared patients when patients' identifying information 
does not match exactly, (2) the Secretary of Defense expedite efforts 
to assign a unique DOD identification number to VA patients who were 
discharged from active duty before 1997, (3) the Secretary of Veterans 
Affairs expedite efforts to expand to all VA sites the capability to 
automatically check DOD data that are exchanged through CHDR, and (4) 
the Secretary of Defense and the Secretary of Veterans Affairs expedite 
the development of written guidelines for all sites to use for defining 
and identifying shared patients. 

Agency Comments: 

In commenting on a draft of this report, DOD and VA concurred with our 
findings and recommendations. (DOD's and VA's comments are reprinted in 
enclosures II and III, respectively.) DOD stated that it will expedite 
efforts for the identified recommendations to be completed by the 
specified time frames. VA stated that the two agencies are taking the 
necessary steps to overcome issues that have hindered their ability to 
exchange computable outpatient pharmacy data for all shared patients. 
DOD and VA provided updated information on their efforts and DOD 
provided technical comments. We incorporated updated information and 
technical comments where appropriate. 

We are sending copies of this report to the Secretary of Defense, the 
Secretary of Veterans Affairs, and appropriate congressional 
committees. We will also provide copies to others upon request. In 
addition, the report is available at no charge on GAO's Web site at 
http://www.gao.gov. 

If you and your staff have any questions or need additional 
information, please contact Laurie Ekstrand at (202) 512-7101 or 
ekstrandl@gao.gov or Valerie Melvin at (202) 512-6304 or 
melvinv@gao.gov. Contact points for our Offices of Congressional 
Relations and Public Affairs may be found on the last page of this 
report. Major contributors to this report were James Musselwhite, 
Assistant Director; Barbara Oliver, Assistant Director; Janina Austin; 
Jacqueline Bauer; Manuel Buentello; Christina C. Serna; and Eric Trout. 

Signed by: 

Laurie E. Ekstrand: 
Director, Health Care: 

Signed by: 

Valerie C. Melvin: 
Acting Director, Information Technology Human Capital and Management 
Issues: 

Enclosures - 3: 

[End of section] 

Enclosure I: Briefing: 

DOD and VA Outpatient Pharmacy Data: Computable Data Are Exchanged for 
Some Shared Patients, but Agencies Have Not Completed Steps Important 
for Exchanging These Data for All Shared Patients: 

Briefing to Congressional Staff: 

Updated: 

DOD and VA Outpatient Pharmacy Data: Computable Data Are Exchanged for 
Some Shared Patients, but Agencies Have Not Completed Steps Important 
for Exchanging These Data for All Shared Patients: 

Congressional Requesters: 

Chairman, Honorable Ike Skelton: 
Ranking Member, Honorable Duncan Hunter: 
House Committee on Armed Services: 

Chairman, Honorable Vic Snyder: 
Ranking Member, Honorable John M. McHugh: 
Subcommittee on Military Personnel: 
House Committee on Armed Services: 

Overview: 

Introduction: 

Objectives: 

Scope and Methodology: 

Background: 

Findings: 

Introduction: 

For decades, Congress has encouraged the Department of Defense (DOD) 
and the Department of Veterans Affairs (VA) to increase their resource- 
sharing activities to help clinicians-physicians and pharmacists- 
deliver health care services more efficiently and increase the quality 
of care provided to those who receive care from both DOD and VA. 

Since 1998, DOD and VA have been working to electronically exchange 
patient health data, including outpatient pharmacy data,[Footnote 5] 
for active duty military personnel and veterans. 

Exchanging outpatient pharmacy data is important for DOD and VA because 
certain DOD and VA patients, known as shared patients, receive health 
care from both agencies. 

There are two ways shared patients may receive care from both DOD and 
VA health care systems. 

1. Through local agreements between DOD and VA, some patients may be 
referred from one agency's facility to the other's for care that the 
referring facility does not provide. 

2. Based on DOD's and VA's respective criteria for health care 
eligibility, some patients may be eligible for care under both systems 
(for example, many military retirees are eligible for both DOD and VA 
health care). 

Clinicians' access to complete health information from both agencies' 
health information systems could assist clinicians in making more 
informed medical decisions. 

Exchange of pharmacy data for shared patients could help prevent 
adverse medication reactions-including detrimental or unintended 
reactions when multiple medications are taken together and allergic 
reactions to a medication. 

The Bob Stump National Defense Authorization Act for Fiscal Year 2003 
required DOD and VA to develop outpatient pharmacy data systems that 
provide a real-time interface, data exchange, and checking of 
prescription drug data using national standards by October 1, 
2004.[Footnote 6] 

In March 2004, DOD and VA began collaborating on a long-term initiative 
to make their patient health data, including outpatient pharmacy data, 
computable. Computable data refer to data that are in a format that a 
computer application can act on: for example, to provide automatic 
checks for adverse medication reactions or to plot graphs of changes in 
vital signs such as blood pressure. 

In reporting on this long-term initiative in the past, we have noted 
that the agencies have experienced delays in their efforts to begin 
exchanging computable outpatient pharmacy data.[Footnote 7] We reported 
that DOD and VA originally planned to begin exchanging computable 
outpatient pharmacy data by October 2005. 

In 2004, DOD and VA also began a separate initiative to electronically 
exchange read-only health data in near real-time for shared patients, 
which would allow DOD and VA clinicians to view data from each other's 
health information system. As of March 2007, all 128 VA sites and 22 of 
138 DOD sites had the capability to electronically view data.[Footnote 
8] 

While DOD and VA officials said the capability to electronically view 
patients' health data from both agencies' systems has improved the 
quality of the health care they provide, agency officials expect 
computable data to further enhance the quality of health care provided. 

The capability of electronic health information systems to check and 
provide alerts for adverse medication reactions supplements, but does 
not replace, clinicians' standard practices of medical care, which 
include asking patients about their medication and medication-allergy 
histories and reviewing patients' medical files for their medication 
histories. 

Objectives: 

1. To describe DOD's and VA's expectations of what the exchange of 
computable outpatient pharmacy data will provide in safeguards against 
adverse medication reactions for shared patients. 

2. To provide the status of DOD's and VA's initiative for attaining 
computable outpatient pharmacy data. 

Scope and Methodology: 

Analyzed documents and interviewed officials from DOD and VA about the 
agencies' efforts to exchange computable outpatient pharmacy data for 
shared patients. 

Viewed demonstrations at medical facilities in the Washington, D.C. 
area of the capabilities of DOD's and VA's electronic health 
information systems. These demonstrations included how clinicians view 
a patient's medication history and are alerted to adverse medication 
reactions, but did not involve computable data. 

Viewed a demonstration in El Paso, Texas of DOD's and VA's initiative 
to exchange computable pharmacy data for shared patients at two co- 
located sites-William Beaumont Army Medical Center and the El Paso VA 
Health Care System-where DOD and VA first exchanged computable pharmacy 
data for shared patients. 

Conducted our work from July 2006 through April 2007 in accordance with 
generally accepted government auditing standards. 

Background: 

DOD patients may receive health care and get medications from several 
points of service. 

DOD patients can receive health care from: 

* DOD military treatment facilities (MTF) at 138 sites, which include 
over 70 hospitals and 400 clinics: 

* Private physicians (network and nonnetwork).[Footnote 9] 

DOD patients can get medications from: 

* MTF pharmacies: 

* DOD's mail order pharmacy: 

* Private pharmacies (network and nonnetwork). 

VA patients may receive health care and get medications from the VA 
health care system. 

VA patients can receive health care from facilities at 128 VA sites, 
which include 155 hospitals and 881 clinics. 

VA patients can obtain medications from VA-facility pharmacies and VA's 
seven mail order pharmacies. 

In some cases, VA uses private physicians to provide care to patients 
who are in need of a service that VA is unable to provide. If one of 
these private physicians prescribes a medication, the medication is 
filled at a VA pharmacy. 

DOD and VA have each developed a repository-centralized electronic 
storage-for health data, including data on medications dispensed and 
patients' allergies to medications. 

Patient health data from DOD's and VA's health care facilities and 
pharmacies are aggregated in local databases maintained at DOD and VA 
sites, respectively. 

Patient data are transferred from DOD sites' local databases to DOD's 
Clinical Data Repository (CDR)[Footnote 10] and from VA sites' local 
databases to VA's Health Data Repository (HDR). 

For example, the El Paso, Texas location has one DOD site and one VA 
site. Patient health data from the DOD site, composed of one medical 
center and two clinics, and the VA site, composed of three clinics, are 
aggregated in each site's database and then transferred to the 
corresponding agency's data repository. 

DOD and VA clinicians can electronically view the medications dispensed 
to patients at any facility in their respective health care systems 
and, in certain cases, view medications dispensed to shared patients in 
the other agency's system. 

MTF physicians and MTF pharmacists can view information identifying 
medications dispensed at all MTF pharmacies, DOD's mail order pharmacy, 
private network pharmacies, and at private nonnetwork pharmacies if a 
claim for reimbursement is submitted. 

However, private physicians and private pharmacists (network and 
nonnetwork) and DOD's mail order pharmacy are unable to electronically 
view information identifying DOD patients' medications. 

In addition, DOD physicians at the facilities associated with the 22 
DOD sites capable of exchanging shared patient data can view 
medications dispensed to shared patients at all VA facility pharmacies. 
These data are not computable. 

VA physicians and pharmacists at all VA facilities can electronically 
view medications dispensed from all VA facility pharmacies, VA's mail 
order pharmacies, and those IVITF pharmacies that exchange shared 
patient data. 

DOD and VA have developed automatic checks and alerts for their 
respective health information systems. 

DOD can perform automatic checks and provide alerts to MTF clinicians 
if a new medication order will have an adverse medication reaction with 
medications previously dispensed within DOD's health care 
system[Footnote 11] - global checks-and medication allergies recorded 
at all MTFs. 

VA can perform automatic checks and provide alerts to VA clinicians if 
a new medication order will have an adverse medication reaction with 
medications ordered and dispensed and medication allergies recorded at 
facilities associated with the same VA site-local checks. 

As of March 2007, health care facilities at 10 VA sites could perform 
global checks on medications ordered and dispensed and medication 
allergies recorded at all VA facilities. 

Exchanging computable data between agencies' health information systems 
requires that the agencies adopt common standards for clinical 
terminologies and for the transmission of information across systems. 

In 2001, the Office of Management and Budget began the Consolidated 
Health Informatics (CHI) initiative, which was a collaborative 
agreement among federal agencies, including DOD and VA, to adopt a 
common set of health information standards for the electronic exchange 
of clinical health information.[Footnote 12] 

As part of the CHI initiative, DOD and VA began to adopt standard 
medication terminologies. 

CHI did not identify common standards for medication allergies. 

Findings: 

DOD and VA Expect Computable Outpatient Pharmacy Data to Allow Seamless 
Access to Shared Patients' Medication Histories and More Complete 
Electronic Checks for Adverse Medication Reactions: 

DOD and VA Are Exchanging Computable Outpatient Pharmacy Data for Some 
Shared Patients, but Have Not Completed Steps Important for Exchanging 
These Data for All Shared Patients: 

DOD and VA Expect Computable Outpatient Pharmacy Data to Allow Seamless 
Access to Shared Patients' Medication Histories and More Complete 
Electronic Checks for Adverse Medication Reactions: 

DOD and VA officials expect information on outpatient medications 
dispensed to shared patients by either agency's health care system to 
be stored in both agencies' health data repositories, which would 
expand the data included in agencies' electronic checks for adverse 
medication reactions. 

Shared patients' health data, including medication and medication- 
allergy data, are to be stored in each agency's repository in the 
standardized vocabulary each agency uses, following translation from a 
standardized set of terms, thus allowing either agency's electronic 
health information system to process the other agency's data as if the 
data had originated in its own system. 

According to DOD and VA officials, this capability is expected to 
enable automatic checks for adverse medication reactions and to enable 
clinicians to receive automatic alerts for any adverse medication 
reactions that have been identified, regardless of which agency's 
facility dispensed the medication or recorded the medication-allergy 
information. 

Automated alerts are intended to inform physicians and pharmacists when 
a newly prescribed medication is potentially adversely reactant to a 
medication previously dispensed or whether a patient has an identified 
allergy to the newly prescribed medication. 

According to DOD and VA officials, using pharmacy data from both DOD 
and VA, rather than data from a single agency, could reduce adverse 
medication reactions by providing more complete checks for shared 
patients. 

DOD officials also expect computable outpatient pharmacy data to 
increase the checking capabilities of private pharmacists in DOD's 
network. 

According to DOD officials, the medications that private pharmacists in 
DOD's network dispense are expected to be checked for detrimental or 
unintended reactions to medications previously dispensed within VA's 
system; the pharmacist is to receive an alert if a potential adverse 
reaction is found. 

DOD and VA Are Exchanging Computable Outpatient Pharmacy Data for Some 
Shared Patients, but Have Not Completed Steps Important for Exchanging 
These Data for All Shared Patients: 

DOD and VA have developed the capability to exchange computable 
outpatient pharmacy data.[Footnote 13] 

DOD and VA have developed an electronic interface-Clinical Data 
Repository/Health Data Repository (CHDR)-that links DOD's CDR and VA's 
HDR and allows for the exchange of computable data between the two data 
repositories. 

Before computable data can be exchanged, patients who use both DOD's 
and VA's health care systems must be identified as shared patients and 
then activated, which refers to shared patients being matched on 
certain identifiers-first name, last name, date of birth, Social 
Security Number-in both agencies' health information systems and 
established as "active" shared patients. 

DOD and VA are currently exchanging computable outpatient pharmacy data 
through CHDR for patients activated at seven locations.[Footnote 14] 

DOD and VA officials said that, as of March 2007, the agencies had 
exchanged computable outpatient pharmacy data for about 4,000 patients 
activated at the seven locations. 

We viewed a successful demonstration of the exchange of computable 
outpatient pharmacy data at one location in El Paso, Texas-the William 
Beaumont Army Medical Center and the El Paso VA Health Care System. 

In addition to El Paso, DOD and VA have begun exchanging computable 
outpatient pharmacy data for patients activated at six other locations: 

* Eisenhower Army Medical Center and Augusta VA Medical Center: 

* Madigan Army Medical Center and VA Puget Sound Health Care System: 

* Mike O'Callaghan Federal Hospital and VA Southern Nevada Health Care 
System: 

* Naval Health Clinic, Great Lakes and North Chicago VA Medical Center: 

* Naval Hospital Pensacola and VA Gulf Coast Veterans Health Care 
System: 

* Naval Medical Center San Diego-Balboa and VA San Diego Health Care 
System: 

Locations of Sites Activating Shared Patients, March 2007: 

[See PDF for image] 

Sources: GAO analysis of DOD and VA information, Map Resources (map). 

[End of figure] 

DOD and VA officials anticipate that all sites in the continental 
United States, Alaska, and Hawaii will activate shared patients. 

DOD officials expect that all 117[Footnote 15] DOD sites in the 
continental United States, Alaska, and Hawaii will be able to activate 
shared patients by the end of June 2007. 

VA officials expect that all 128[Footnote 16] VA sites will be able to 
activate shared patients by mid-September 2007. 

Although all sites are not currently activating shared patients, 
officials indicated that all DOD and VA sites can exchange computable 
pharmacy data for patients previously activated at other sites. 

DOD and VA have been addressing issues that the agencies acknowledge 
have hindered their ability to exchange all computable outpatient 
pharmacy data for activated shared patients. 

Because a national standard does not exist for medication-allergy data, 
DOD and VA have agreed on and adopted a standard for exchanging these 
data. 

Adopted standard medication terminologies do not include terminologies 
for all medications. 

Standard medication terminologies must be continuously updated as new 
medications become available. 

DOD and VA have developed a team to review data that cannot be 
exchanged[Footnote 17] and to work toward improving the percentage of 
data that can be exchanged. 

DOD and VA have been exchanging computable outpatient pharmacy data. 

Percentage of Data Exchanged on Medications Dispensed and on Medication-
allergies for Shared Patients Activated as of December 2006: 

Data: VA to DOD; 
Medications dispensed: 90; 
Medication allergies: 78. 

Data: DOD to VA; 
Medications dispensed: 93; 
Medication allergies: 65. 

Source: DOD and VA officials. 

Note: According to DOD and VA officials, approximately 3,500 shared 
patients were activated as of December 2006. Data may not exchange for 
several reasons, including lack of standard terminologies and 
formatting errors. 

[End of table] 

DOD and VA have been addressing issues that the agencies acknowledged 
have hindered their ability to activate all shared patients. 

According to DOD and VA officials, in some cases, patient information 
does not match exactly on all identifiers. 

For example, patients may present themselves using a nickname for one 
system and a full name for the other system. In these instances, DOD 
and VA cannot activate these patients. 

DOD assigns a unique number to DOD beneficiaries, which is needed to 
activate shared patients. However, VA patients who were discharged from 
active duty before 1997 may not have this unique number. 

Without this unique number, patients cannot be recognized by DOD's PDTS 
and therefore cannot be activated as shared patients. 

To help resolve problems with matching patients' identifying 
information, DOD reported that in February 2007 it completed a software 
upgrade that officials expect will reduce DOD's error rate for 
activating shared patients to less than 5 percent. Similarly, VA 
officials told us that VA is developing a software upgrade, but could 
not provide a date for when the upgrade would be operational. 

For VA patients lacking a unique DOD number, DOD reported that it is 
working with a VA-provided list of patients who are receiving care from 
VA and were discharged from active duty before 1997. DOD reported that 
it will create unique identification numbers for these patients and 
anticipates this effort will be completed by the end of September 2007. 

VA must expand its current capability to conduct global automatic 
checks to all VA sites before all sites can benefit from automatic 
checks allowed by computable outpatient pharmacy data.[Footnote 18] 

The capability for VA sites to conduct global automatic checks of 
medications ordered and dispensed and medication allergies recorded at 
all VA facilities is needed for all VA sites to conduct more 
comprehensive checks across all VA sites and to automatically check DOD 
data that are exchanged through CHDR. 

The capability allows VA's health information system to process data 
originating from DOD as though the data originated from another VA 
site. 

VA officials told us that until the capability for global automatic 
checks is in place at a VA site, the VA site will likely not activate 
shared patients. 

VA officials said that as of March 2007 this capability is in place at 
10 sites and expect it to be in place at all VA sites by the end of 
July 2007. 

According to DOD and VA officials, the agencies have not established 
written guidelines for all sites to use for identifying shared 
patients. 

DOD and VA officials told us they instructed the seven locations that 
are currently activating patients to identify shared patients as those 
who have previously received care from both agencies. 

DOD and VA officials told us that guidelines for all sites to use for 
identifying shared patients, including criteria defining a shared 
patient and procedures for identifying shared patients, would help 
sites determine which patients should be activated. However, the 
agencies have not established written guidelines for all sites. 

Agency officials stated that the development of guidelines for all 
sites to use are under way and DOD expects the guidelines to be 
completed by the end of June 2007. Officials said that customization of 
the guidelines may be necessary because of site-specific situations, 
such as local agreements. 

[End of section] 

Enclosure II: Comments from the Department of Defense: 

The Assistant Secretary Of Defense: 
1200 Defense Pentagon: 
Washington, DC 203011200: 
Health Affairs: 

Apr 1 3 2007: 

Ms. Laurie E. Ekstrand: 
Director, Health Care: 
U.S. Government Accountability Office: 
441 G Street, N.W. 
Washington, DC 20548: 

Dear Ms. Ekstrand: 

This is the Department of Defense (DoD) response to the U.S. Government 
Accountability Office (GAO) draft report, "DoD and Veterans Affairs 
Outpatient Pharmacy Data: Computable Data Are Exchanged for Some Shared 
Patients, but Additional Steps Could Facilitate Exchanging These Data 
for All Shared Patients," dated April 4, 2007 (GAO Code 290552/GAO-07- 
554-R). 

The DoD acknowledges receipt of the GAO draft report and concurs with 
the overall findings and recommendations. Specifically, DoD will 
expedite efforts for the identified recommendations to be completed by 
the specified timeframes. 

Enclosed are specific responses and two technical comments to GAO's 
draft report recommendations. Please feel free to direct any questions 
on this matter to our Project Officer, Ms. Pamela Schmidt, at (703) 681-
8830, or Mr. Gunther Zimmerman (GAO Liaison), at (703) 681-3492. 

Sincerely, 

Signed by: 

William Winkenwerder, Jr., MD: 

Enclosures: 
As stated: 

GAO Draft Report - Dated April 4, 2007 GAO Code 290552/GAO-07-554R: 

"DoD and VA Outpatient Pharmacy Data: Computable Data Are Exchanged for 
Some Shared Patients, but Additional Steps Could Facilitate Exchanging 
These Data for All Shared Patients" 

Department Of Defense Comments To The Recommendations: 

Recommendation 1: The GAO recommends that the Secretary of Defense and 
the Secretary of Veterans Affairs expedite efforts to develop a 
solution for activating shared patients when patients' identifying 
information does not match exactly. (pgs. 3-4/GAO Draft Report): 

DoD Response: Concur. The DoD and VA are working collaboratively to 
resolve this issue. A DoD system upgrade completed Feb 2007 is expected 
to reduce the error rate for activating shared patients to less than 5 
percent. 

Recommendation 2: The GAO recommends that the Secretary of Defense and 
the Secretary of Veterans Affairs expedite efforts to assign a unique 
DOD identification number to VA patients who were discharged from 
active duty before 1997. (pg. 4/GAO Draft Report): 

DoD Response: Concur. In the Common Population project, the VA is 
working with Defense Manpower Data Center (DMDC) to add the VA patients 
who were discharged from active duty prior to 1997 and are receiving 
health care in VA. Once the listing of VA patients is received by DMDC, 
it will take approximately 30 days to create the unique identification 
numbers. We anticipate this work will be completed in 4Q FY 2007. 

Recommendation 4: The GAO recommends that the Secretary of Defense and 
the Secretary of Veterans Affairs expedite the development of written 
guidelines for all sites to use for defining and identifying shared 
patients. (pg. 4/ GAO Draft Report): 

DoD Response: Concur. The DoD currently has guidelines under 
development and in coordination with the Services. We expect to 
complete this task in 3Q FY 2007. 

[End of section] 

Enclosure III: Comments from the Department of Veterans Affairs: 

The Secretary Of Veterans Affairs: 
Washington: 

April 18, 2007: 

Ms. Laurie Ekstrand: 
Director, Health Care: 
and: 
Ms. Valerie C. Melvin: 
Acting Director, Information Technology: 
Human Capital and Management Issues: 
U. S. Government Accountability Office: 
441 G Street, NW: 
Washington, DC 20548: 

Dear Ms. Ekstrand and Ms Melvin: 

The Department of Veterans Affairs (VA) has reviewed your draft report, 
DOD and VA Outpatient Pharmacy Data: Computable Data Are Exchanged for 
Some Shared Patients, but Additional Steps Could Facilitate Exchanging 
These Data for All Shared Patients (GAO-07-554R) and agrees with your 
conclusions and concurs in your recommendations directed to VA. 

While VA and DoD have encountered certain obstacles that have hindered 
our ability to exchange computable outpatient pharmacy data for all 
active dual consumers, both agencies are taking the necessary steps to 
overcome these issues. VA and DoD are well on the path to accomplishing 
a critical milestone in our ability to electronically exchange multiple 
types of patient health data between our health information systems. By 
September 14, 2007, all 128 VA sites will be able to activate shared 
patients. Considering that VA and DoD, in many respects, are at the 
forefront of facilitating electronic health data exchange across 
disparate information systems, this will be a notable accomplishment in 
our continuing efforts to provide high quality care for both active 
duty service members and veterans. 

The enclosure details VA steps to implement your recommendations 
directed to the Department of Veterans Affairs. VA appreciates the 
opportunity to comment on your draft report. 

Sincerely yours, 

Signed by: 

R. James Nicholson: 

Enclosure: 

Department of Veterans Affairs (VA) comments to Government 
Accountability Office (GAO) draft report DOD and VA Outpatient Pharmacy 
Data: Computable Data Are Exchanged for Some Shared Patients, but 
Additional Steps Could Facilitate Exchanging These Data for All Shared 
Patients (GAO-07-554R): 

To help ensure that all shared patients benefit from the exchange of 
computable outpatient pharmacy data, the Secretary of Defense and the 
Secretary of Veterans Affairs should expedite certain ongoing efforts. 
Specifically, GAO recommends that: 

* the Secretary of Defense and the Secretary of Veterans Affairs 
expedite efforts to develop a solution for activating shared patients 
when patients' identifying information does not match exactly. 

Concur - The Veterans Health Administration (VHA) acknowledges the 
necessity to improve the rate of matching between DoD and VA patients 
for whom computable pharmacy data are shared when their identifying 
information does not exactly match. VHA is working with DoD to provide 
a VA file that will permit DoD to match patients and issue Defense 
Enrollment Eligibility Reporting System (DEERS) ID numbers for those 
veterans who do not have already have one and are reasonably expected 
to receive care from both systems (i.e., registered in the VA Master 
Patient Index). This work includes activities to ensure that the 
proposed solution meets all applicable security and privacy 
requirements. 

* the Secretary of Veterans Affairs expedite efforts to expand to all 
VA sites the capability to automatically check DOD data that are 
exchanged through CHDR. 

Concur - VHA acknowledges the necessity to expand Clinical Data 
Repository/Health Data Repository (CHDR) capability for automatic drug 
and allergy checks to all 128 VA (Veterans Health Information Systems 
and Technology Architecture [VistA]) sites. In order to expand 
capability to all VA sites, VHA is currently working to complete 
testing on the Remote Data Interoperability (RDI) application and to 
approve RDI for national release. RDI is the application that supports 
the ability of VA to conduct the checks against data in the Health Data 
Repository (remote VA data and DoD data). 

* the Secretary of Defense and the Secretary of Veterans Affairs 
expedite the development of written guidelines for all sites to use for 
defining and identifying shared patients. 

Concur - VA and Doll) have completed the written guidelines and are 
currently planning to jointly present them to the Health Executive 
Council (HEC) Information Management/Information Technology (IMIT) 
workgroup on April 26, 2007, for approval. 

[End of section] 

(290552): 

FOOTNOTES 

[1] Patient health data also include demographic, radiology, 
laboratory, and allergy data. Outpatient pharmacy data refer to 
information on medications dispensed and medication allergies. 

[2] GAO, Information Technology: VA and DOD Face Challenges in 
Completing Key Efforts, GAO-06-905T (Washington, D.C.: June 22, 2006). 

[3] Each location includes one DOD site and one VA site at the same 
location or in close proximity. A site represents one or more 
facilities--medical centers, hospitals, or outpatient clinics--that 
store their electronic health data in a single database. 

[4] According to DOD officials, there are a total of 138 sites, 21 of 
which are located outside the United States and will likely not 
activate patients. 

[5] Patient health data also include demographic, radiology, 
laboratory, and allergy data. Outpatient pharmacy data refer to 
information on medications dispensed and medication allergies. 

[6] Pub. L. No. 107-314,  724, 116 Stat. 2458, 2598 (2002). In 
September 2004, the agencies completed testing of a prototype that 
allowed their systems to demonstrate these capabilities. 

[7] GAO, Information Technology. VA and DOD Face Challenges in 
Completing Key Efforts, GAO-06-905T (Washington, D.C.: June 22, 2006). 

[8] A site represents one or more facilities-medical centers, 
hospitals, or outpatient clinics-that store their electronic health 
data in a single database. 

[9] Network refers to TRICARE's network-a regionally structured program 
that uses civilian contractors to maintain provider and pharmacy 
networks to complement health care services provided at MTFs. 

[10] Information on medications dispensed is aggregated and transferred 
to CDR by DOD's Pharmacy Data Transaction Service (PDTS). DOD also uses 
PDTS for pharmacy billing and for verifying whether patients are 
eligible for DOD pharmacy benefits. 

[11] Medications previously dispensed within DOD's health care system 
include medications dispensed at MTFs, DOD's mail order pharmacy, 
private network pharmacies, and at private nonnetwork pharmacies if a 
claim for reimbursement is submitted. 

[12] According to DOD and VA officials, on September 30, 2006, the CHI 
initiative was dissolved and will be integrated with the Health 
Information Technology Standards Panel, a public-private collaborative 
effort. 

[13] DOD and VA envision exchanging other computable patient health 
data through CHDR. Agency officials indicated that they also have 
efforts underway to develop the capability to exchange computable 
clinical laboratory data. 

[14] Each location represents one DOD site and one VA site in the same 
location or in close proximity. 

[15] According to DOD officials, 21 of the agency's 138 sites are 
outside the United States and will likely not activate patients. 

[16] According to VA officials, all of the agency's 128 sites are 
within the United States. 

[17] Data may not be exchanged for reasons other than lack of 
standards, including formatting errors. 

[18] All DOD sites currently have the capability to conduct global 
automatic checks. 

GAO's Mission: 

The Government Accountability Office, the audit, evaluation and 
investigative arm of Congress, exists to support Congress in meeting 
its constitutional responsibilities and to help improve the performance 
and accountability of the federal government for the American people. 
GAO examines the use of public funds; evaluates federal programs and 
policies; and provides analyses, recommendations, and other assistance 
to help Congress make informed oversight, policy, and funding 
decisions. GAO's commitment to good government is reflected in its core 
values of accountability, integrity, and reliability. 

Obtaining Copies of GAO Reports and Testimony: 

The fastest and easiest way to obtain copies of GAO documents at no 
cost is through GAO's Web site (www.gao.gov). Each weekday, GAO posts 
newly released reports, testimony, and correspondence on its Web site. 
To have GAO e-mail you a list of newly posted products every afternoon, 
go to www.gao.gov and select "Subscribe to Updates." 

Order by Mail or Phone: 

The first copy of each printed report is free. Additional copies are $2 
each. A check or money order should be made out to the Superintendent 
of Documents. GAO also accepts VISA and Mastercard. Orders for 100 or 
more copies mailed to a single address are discounted 25 percent. 
Orders should be sent to: 

U.S. Government Accountability Office 441 G Street NW, Room LM 
Washington, D.C. 20548: 

To order by Phone: Voice: (202) 512-6000 TDD: (202) 512-2537 Fax: (202) 
512-6061: 

To Report Fraud, Waste, and Abuse in Federal Programs: 

Contact: 

Web site: www.gao.gov/fraudnet/fraudnet.htm E-mail: fraudnet@gao.gov 
Automated answering system: (800) 424-5454 or (202) 512-7470: 

Congressional Relations: 

Gloria Jarmon, Managing Director, JarmonG@gao.gov (202) 512-4400 U.S. 
Government Accountability Office, 441 G Street NW, Room 7125 
Washington, D.C. 20548: 

Public Affairs: 

Paul Anderson, Managing Director, AndersonP1@gao.gov (202) 512-4800 
U.S. Government Accountability Office, 441 G Street NW, Room 7149 
Washington, D.C. 20548: