	Background

VHA provides health care to approximately 6.7 million veterans and their  families at an estimated annual cost of about $56 billion. This includes multiple computer applications which have  pharmacy capabilities. VA Has Pharmacy System Capabilities, but Inefficiencies Exist in Viewing and Transferring Data

VA currently has system capabilities that support clinicians and  pharmacists in prescribing and dispensing medications to patients. Pharmacists Cannot Transfer Prescriptions to Other VHA Pharmacies

Beyond limitations in viewing patient data, pharmacists lack the capacity  to electronically transfer prescriptions to other VHA pharmacies or  process prescription refills received from other VHA medical sites. Nevertheless, certain  limitations impede interoperability with DOD: VA clinicians and  pharmacists (1) cannot always view DOD patient data and (2) do not  always receive complete order checks  that include new DOD  medication data. Further, VA has not assessed the impact of its  pharmacy system interoperability on service members transitioning care  from DOD to VA.

		VA’s Pharmacy System Enables Interoperability Capabilities with DOD, but Clinicians and Pharmacists Cannot Always View Data or Receive Complete Order Checks

The National Defense Authorization Act for Fiscal Year 2003 required VA  and DOD systems to be interoperable, to achieve real-time interface and  data exchange, and to have the ability to check prescription drug  information for outpatients. In addition, VA pharmacists and clinicians do not always receive complete  information from DOD’s pharmacy system that is needed to perform  medication order checks on new medications. Further, in the absence of such an  assessment, VA lacks assurance regarding the effectiveness of its  pharmacy system to adequately support its mission of providing health  care to veterans. These practices focus on enabling clinicians and/or  pharmacists to (1) order medications electronically, (2) receive drug-to- drug and drug-allergy interaction checks, (3) track the dispensing of  controlled prescription drugs, (4) electronically exchange prescriptions  with non-VA entities (i.e., private or DOD clinicians and pharmacies), (5)  utilize clinical decision support capabilities, and (6) maintain a perpetual  inventory management capability to monitor medication inventory levels. VA’s Pharmacy System Has Not Incorporated Three Practices That Could Enhance Its Usefulness

While VA’s system includes capabilities that are consistent with three of  the selected industry practices, the department has not implemented  capabilities that align with three other selected practices that could  enhance its pharmacy system’s usefulness. As a result, veterans must obtain paper  prescriptions or have prescriptions faxed from non-VA providers, and  submit the prescriptions to their local VA medical sites in order for the VA  pharmacy to manually input the prescriptions into the system and fill  them—a process that is time consuming and inefficient. VA’s health information system, VistA, including CPRS, does not have  capabilities that could enhance clinical decision support for patient  treatment. Moreover, VA has not assessed the  impact that these shortcomings and its pharmacy system interoperability  with DOD have on veterans. Lacking these capabilities, the department will  continue to be limited in its ability to exchange prescriptions with non-VA  providers, provide additional clinical decision support, and track  medication which could impact veteran patient safety. Recommendations for Executive Action

To provide clinicians and pharmacists with improved tools to support  pharmacy services to veterans and reduce risks to patient safety, we  recommend that the Secretary of Veterans Affairs direct the Assistant  Secretary for Information and Technology and the Under Secretary for  Health to take the following six actions: establish and implement a plan for updating the pharmacy system to  address the inefficiencies with viewing patient medication data in the  Outpatient Pharmacy application and between the pharmacy  application and viewers; complete a plan for the implementation of an approach to data  standardization that will support the capability for clinicians and  pharmacists to view complete DOD data and receive order checks  that consistently include DOD data; conduct an assessment to determine to what extent interoperability  of  VA’s pharmacy system with DOD’s pharmacy system is impacting  transitioning service members; develop and execute a plan for implementing the capability to send  outbound e-prescriptions to non-VA pharmacies, in accordance with  National Council for Prescription Drug Programs standards; ensure that the department’s evaluation of alternatives for electronic  health records includes consideration for additional generation level 3  capability such as navigating from an alert to medication order in the  electronic health record system; and  reassess the priority for establishing an inventory management  capability to monitor and update medication levels and track when to  reorder medications. Our objectives were to determine whether: (1)  VA currently possesses a functioning pharmacy system and the extent to  which the system enables data to be viewed, shared, and transferred  among Veteran’s Health Administration (VHA) pharmacy locations; (2)  VA’s pharmacy system is interoperable with the Department of Defense’s  (DOD), and whether this system, or the absence thereof, is impacting  service members who transition care from DOD; and (3) VA has  implemented its pharmacy system in accordance with health care industry  practices.
Why GAO Did This Study

VHA provides health care services, including pharmacy services, to approximately 6.7 million veterans and their families. To do so, clinicians and pharmacists rely on VA's health information system. The National Defense Authorization Act for Fiscal Year 2003 required VA to ensure it has a pharmacy system that is interoperable with DOD's system.
A provision in Senate Report 114-57 required GAO to examine VA's acquisition and use of a pharmacy system. GAO determined whether (1) VA currently possesses a functioning pharmacy system and the extent to which the system enables data to be viewed, shared, and transferred among VHA pharmacy locations; (2) VA's pharmacy system is interoperable with DOD's, and whether this system, or the absence thereof, is impacting service members who transition care from DOD; and (3) VA has implemented its pharmacy system in accordance with health care industry practices. GAO analyzed documentation describing VA's pharmacy system; observed system demonstrations; analyzed plans and actions taken to achieve interoperability with DOD; and identified industry practices related to pharmacy systems, and compared them to VA's system capabilities.

What GAO Found

The Department of Veterans Affairs (VA) has system capabilities through multiple computer applications that support its clinicians and pharmacists in prescribing and dispensing medications to patients. However, pharmacists cannot always efficiently view necessary patient data among Veterans Health Administration (VHA) medical sites. In addition, pharmacists cannot transfer prescriptions to other VHA pharmacies or process prescription refills received from other VHA medical sites through the system. As a result, the system does not provide important capabilities for pharmacists to make clinical decisions about prescriptions efficiently, which could negatively affect patient safety.
In its efforts to establish and increase interoperability with the Department of Defense (DOD), VA has developed capabilities to exchange certain patient and medication information. For example, VA's pharmacy system has the ability to check prescription drug information from DOD. Nevertheless, limitations impede interoperability with DOD: (1) VA clinicians and pharmacists cannot always view DOD patient data and (2) VA pharmacists do not always receive complete information from DOD to perform prescription checks on new medications. Also, VA has not assessed the impact of its pharmacy system interoperability on service members transitioning from DOD to VA, and VHA officials stated that doing so would be difficult because there are other personnel related-factors that could affect patient-care outcomes. Without assessing the impact that pharmacy system interoperability is having on veterans, VA lacks assurance regarding the effectiveness of the system to adequately support its mission of providing health care to veterans.
VA's pharmacy system capabilities align with three of six identified health care industry practices. Specifically, the pharmacy system (1) provides the ability to order medications electronically, (2) enables prescription checks for drug-to-drug and drug-allergy interactions, and (3) tracks the dispensing of controlled prescription drugs. However, the pharmacy system lacks capabilities that align with three other practices which could enhance its usefulness:
Pharmacists cannot electronically exchange prescriptions with non-VA providers and pharmacies. Therefore, veterans need to obtain paper prescriptions from external providers or have the providers fax the prescriptions to their local VA pharmacy to fill the prescriptions, which is time consuming and inefficient.
VA's system does not include certain clinical decision and workflow capabilities that, among other things, could improve clinicians' and pharmacists' ability to provide enhanced medical care to veterans. VA has indicated that it plans to implement such capabilities, but its plans for doing so are incomplete.
VA's system does not maintain a perpetual inventory management capability to monitor medication inventory levels. Therefore, pharmacists cannot effectively track when to reorder medications.
In the absence of these capabilities, VA is limited in its ability to interoperate with private providers, provide additional clinical decision support, and more effectively track medications that could impact veterans' patient safety.

What GAO Recommends

GAO is making six recommendations including that VA update its pharmacy system to view and receive complete medication data, assess the impact of interoperability, and implement additional industry practices. VA generally concurred with GAO's six recommendations.