VA and Defense Health Care:

Increased Risk of Medication Errors for Shared Patients

GAO-02-1017: Published: Sep 27, 2002. Publicly Released: Sep 27, 2002.

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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.

Status Legend:

More Info
  • Review Pending-GAO has not yet assessed implementation status.
  • Open-Actions to satisfy the intent of the recommendation have not been taken or are being planned, or actions that partially satisfy the intent of the recommendation have been taken.
  • Closed-implemented-Actions that satisfy the intent of the recommendation have been taken.
  • Closed-not implemented-While the intent of the recommendation has not been satisfied, time or circumstances have rendered the recommendation invalid.
    • Review Pending
    • Open
    • Closed - implemented
    • Closed - not implemented

    Recommendations for Executive Action

    Recommendation: To better protect shared patients at the joint ventures, the Secretary of Veterans Affairs should direct the Under Secretary for Health and the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs to 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.

    Agency Affected: Department of Defense

    Status: Closed - Not Implemented

    Comments: In comments to GAO's draft report, VA concurred and DOD non-concurred with GAO's recommendation on establishing a joint Pharmacy and Therapeutics (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. It suggested using its own formulary system for joint venture sites. DOD did not concur with establishing a joint P&T committee at each site. VA and DOD do not plan to establish joint Pharmacy and Therapeutics committees or similar working groups at each joint venture site. According to VA and DOD officials, the VA/DOD executive committee has determined that differences in VA and DOD pharmacy systems make joint local Pharmacy and Therapeutics or similar committees impractical, and VA and DOD do not plan to reconcile these differences. VA operates a "ceiling" formulary, determined at the national and VISN (regional) levels, which includes 95 percent of drugs that are prescribed. Local facilities may not establish separate formularies, although physicians can prescribe non-formulary drugs through a special procedure. DOD also has a national formulary, but includes on it only about 160 "core" drugs that all pharmacies must offer. Local pharmacy and therapeutics committees then have the authority to add whatever other drugs they deem appropriate. Because of these differences in the types of formularies and the levels (local/regional/national) of decision-making, VA and DOD do not plan to implement this recommendation. According to VA officials, future joint venture sites may be established using the same formulary system. If so, then joint local committees will be practical.

    Recommendation: To better protect shared patients at the joint ventures, the Secretary of Veterans Affairs should direct the Under Secretary for Health and the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs to 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.

    Agency Affected: Department of Veterans Affairs

    Status: Closed - Not Implemented

    Comments: Where available, VA providers are required to use computerized order entry of medications for all patients. Where the capability is unavailable within the VA system, VA is working to implement it, but full electronic entry will take at least 2 to 3 years. In a meeting on September 3, 2003, VA and DOD agreed to include interoperability--dispensing drugs in each others' pharmacies--in their long-term plan for technology upgrades. However, this feature is a low priority relative to others because policy decisions must first be made concerning the different VA and DOD formulary rules and billing across systems. According to VA and DOD, a date for the availability of this capability has not been established.

    Recommendation: To better protect shared patients at the joint ventures, the Secretary of Veterans Affairs should direct the Under Secretary for Health and the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs to 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.

    Agency Affected: Department of Veterans Affairs

    Status: Closed - Not Implemented

    Comments: The Department concurs with the recommendation to require providers to use computerized provider order entry (CPOE) of medications for shared patients where CPOE it is available. However, it is the Department's opinion that implementing system modifications as an approach to enable providers to electronically order medications to be dispensed at the other agency's pharmacies would waste resources and falls short of providing total interoperability of both agencies' pharmacy operations. DOD health care providers currently uses Armed Forces Health Longitudinal Technology Application (AHLTA) the military's electronic health record at all military treatment facilities worldwide to support clinical services, to include use of CPOE to order medications. The Service medical departments have provided applicable guidance addressing the deployment and use of AHLTA.

    Recommendation: To better protect shared patients at the joint ventures, the Secretary of Veterans Affairs should direct the Under Secretary for Health and the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs to 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 Pharmacy Data Transaction Service to be used for this purpose.

    Agency Affected: Department of Defense

    Status: Closed - Implemented

    Comments: The Department concurs with both aspects of the recommendation at joint venture sites. In 1st quarter of fiscal year 2007, DOD and VA began deployment of Clinical Data Repository/Health Data Repository (CHDR). CHDR will enable DOD and VA providers automatic checks for adverse drug reactions and regardless of which agency's facility dispensed the medication information. The Military Health System announced enterprise-wide deployment of CHDR in December of 2007.

    Recommendation: To better protect shared patients at the joint ventures, the Secretary of Veterans Affairs should direct the Under Secretary for Health and the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs to 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 Pharmacy Data Transaction Service to be used for this purpose.

    Agency Affected: Department of Defense

    Status: Closed - Not Implemented

    Comments: VA and DOD have achieved the successful bi-directional exchange of computable allergy and pharmacy data through an interface between DOD Clinical Data Repository and the VA Health Data Repository known as the Clinical Data Repository/Health Data Repository (CHDR). CHDR will provide each agency with seamless access to shared patients medication histories and supports automatic drug and allergy interaction checks using medication information from VA and DOD health systems. Development of the CHDR pharmacy/allergy application software is complete and is available at all sites. However, VA implementation of CHDR at each site involves a manual process of designating or marking patients as "active dual consumers." At this time, VA has not expanded the active dual consumer marking capability beyond the initial seven sites.

    Recommendation: To better protect shared patients at the joint ventures, the Secretary of Veterans Affairs should direct the Under Secretary for Health and the Secretary of Defense should 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.

    Agency Affected: Department of Defense

    Status: Closed - Implemented

    Comments: In 1st quarter of fiscal year 2007, DOD and VA began deployment of Clinical Data Repository/Health Data Repository (CHDR). CHDR will allow providers at DOD and VA the ability to view patient medication and allergy information regardless of which department the information originated. The Military Health System announced enterprise-wide deployment of CHDR in December of 2007. Training materials for CHDR were distributed in 4th Quarter fiscal year 2007.

    Recommendation: To better protect shared patients at the joint ventures, the Secretary of Veterans Affairs should direct the Under Secretary for Health and the Secretary of Defense should 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.

    Agency Affected: Department of Veterans Affairs

    Status: Closed - Not Implemented

    Comments: VA and DOD have achieved the successful bi-directional exchange of computable allergy and pharmacy data through an interface between DOD Clinical Data Repository and the VA Health Data Repository known as the Clinical Data Repository/Health Data Repository (CHDR). CHDR will provide each agency with seamless access to shared patients' medication histories. Development of the CHDR pharmacy/allergy application software is complete and is available at all sites. However, VA implementation of CHDR at each site involves a manual process of designating or marking patients as "active dual consumers." At this time, VA has not expanded the active dual consumer marking capability beyond the initial seven sites.

    Recommendation: To better protect shared patients at the joint ventures, the Secretary of Veterans Affairs should direct the Under Secretary for Health and the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs to 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.

    Agency Affected: Department of Defense

    Status: Closed - Not Implemented

    Comments: VA concurred with GAO's recommendation on establishing a joint Pharmacy and Therapeutics (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. It suggested using its own formulary system for joint venture sites. DOD did not concur with establishing a joint P&T committee at each site. VA and DOD do not plan to establish joint Pharmacy and Therapeutics committees or similar working groups at each joint venture site. According to VA and DOD officials, the VA/DOD executive committee has determined that differences in VA and DOD pharmacy systems make joint local Pharmacy and Therapeutics or similar committees impractical, and VA and DOD do not plan to reconcile these differences. VA operates a "ceiling" formulary, determined at the national and VISN (regional) levels, which includes 95 percent of drugs that are prescribed. Local facilities may not establish separate formularies, although physicians can prescribe non-formulary drugs through a special procedure. DOD also has a national formulary, but includes on it only about 160 "core" drugs that all pharmacies must offer. Local pharmacy and therapeutics committees then have the authority to add whatever other drugs they deem appropriate. Because of these differences in the types of formularies and the levels (local/regional/national) of decision-making, VA and DOD do not plan to implement this recommendation. According to VA officials, future joint venture sites may be established using the same formulary system. If so, then joint local committees will be practical.

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