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: Published: Apr 30, 2007. Publicly Released: Apr 30, 2007.

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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, cross 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, GAO noted that the agencies have experienced delays in their efforts to begin exchanging computable outpatient pharmacy data. Concerned about DOD's and VA's progress in this effort, Congress asked GAO to examine the initiative that the agencies have under way to make their outpatient pharmacy data computable. In this report, GAO provides information on (1) 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, and (2) the status of DOD's and VA's initiative for attaining computable outpatient pharmacy data.

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. 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. DOD and VA have begun exchanging computable outpatient pharmacy data through CHDR for patients activated at seven locations as of March 2007. In addition, DOD officials indicated that all 117 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 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. 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.

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 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 the development of written guidelines for all sites to use for defining and identifying shared patients.

    Agency Affected: Department of Veterans Affairs

    Status: Closed - Implemented

    Comments: Consistent with GAO's recommendation, the Department of Defense and VA have developed written guidelines for all sites for defining and identifying shared patients.

    Recommendation: To help ensure that all shared patients benefit from the exchange of computable outpatient pharmacy data, the Secretary of Veterans Affairs should expedite efforts to expand to all VA sites the capability to automatically check DOD data that are exchanged through CHDR.

    Agency Affected: Department of Defense

    Status: Closed - Implemented

    Comments: Consistent with GAO's recommendation, to ensure all shared patients benefit from the exchange of computable pharmacy data. VA has nationally released Remote Data Interoperability (RDI) to all sites, which gives VA the capability to check data exchanged through CHDR. However, 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. VA has not expanded the active dual consumer marking capability beyond seven sites. VA is currently conducting an internal technical review to determine the schedule to expand the active dual consumer marking capability. 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.

    Recommendation: To help ensure that all shared patients benefit from the exchange of computable outpatient pharmacy data, the Secretary of Defense should expedite efforts to assign a unique DOD identification number to VA patients who were discharged from active duty before 1997.

    Agency Affected: Department of Veterans Affairs

    Status: Closed - Implemented

    Comments: VA patients who were discharged from active duty before 1997 may not have a unique identification number DOD assigns to its beneficiaries, and without this number, these patients cannot be activated. DOD's Defense Enrollment Eligibility Reporting System (DEERS) assigns patients in its system with the unique identification number needed to activate these patients for Clinical Data Repository/Health Data Repository (CHDR). Consistent with GAO's recommendation, DOD entered data for those Veterans Affairs beneficiaries not previously in the DEERS.

    Recommendation: 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 efforts to develop a solution for activating shared patients when patients' identifying information does not match exactly.

    Agency Affected: Department of Veterans Affairs

    Status: Closed - Implemented

    Comments: VA concurs with the recommendation. VA and DOD completed the work to update the Defense Enrollment Eligibility Reporting System (DEERS) system to support the increased identification of active dual consumers. Since the inception of this capability, the Military Health System has worked to reduce the error rate for activating shared patients to less than 5 percent. According to a DOD Automated Activation Rate Report for October 2008 through July 2009, a 1 percent average activation error rate had been achieved.

    Recommendation: 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 efforts to develop a solution for activating shared patients when patients' identifying information does not match exactly.

    Agency Affected: Department of Defense

    Status: Closed - Implemented

    Comments: A DOD system upgrade completed is expected to reduce the error rate for activating shared patients to less than 5 percent. According to DOD, an automated capability for activating shared patients was implemented in 9/08 and is being operationalized across DOD and VA. The automated capability collects historical beneficiary information collected/stored by the Bidirectional Health Information Exchange and transfers that data to the Clinical Data Repository/Health Data Repository. According to a DOD Automated Activation Rate Report for October 2008 through July 2009, a 1 percent average activation error rate had been achieved.

    Recommendation: 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 the development of written guidelines for all sites to use for defining and identifying shared patients.

    Agency Affected: Department of Defense

    Status: Closed - Implemented

    Comments: Consistent with GAO's recommendation, the DOD and VA have developed written guidelines for all sites for defining and identifying shared patients.

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