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	 
(30-APR-07, GAO-07-554R).					 
                                                                 
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.							 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-07-554R					        
    ACCNO:   A68885						        
  TITLE:     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	 
     DATE:   04/30/2007 
  SUBJECT:   Data collection					 
	     Data storage					 
	     Drugs						 
	     Electronic data processing 			 
	     Health resources utilization			 
	     Hospital care services				 
	     Medical information systems			 
	     Patient care services				 
	     Schedule slippages 				 
	     Systems compatibility				 
	     Interagency relations				 
	     Data sharing					 
	     Clinical Data Repository/Health Data		 
	     Repository 					 
                                                                 

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GAO-07-554R

   

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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,^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.

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

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.^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

           o 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.

           o 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.^3 In addition, DOD
officials indicated that all 117^4 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.

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

           o 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.

           o 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.

           o 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.

^3Each 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.

^4According 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.

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 [email protected]
or Valerie Melvin at (202) 512-6304 or [email protected] . 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.

Laurie E. Ekstrand
Director, Health Care

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

Enclosures - 3

Enclosure 1

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

Enclosure II

                    Comments from the Department of Defense
					
Enclosure III

                Comments from the Department of Veterans Affairs

(290552)

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