and Surgery (BUMED) also support having separate primary care clinics. For example, the VA requires an appointment within 7 days, and BUMED requires one within 14 days.

Many VA clinicians were part-time (see Table 4-1) at the NCVAMC, available only several times a week. The Navy had a full-time gynecologist, orthopedist, otolaryngologist, dermatologist, and urologist. Although only dermatology and otolaryngology are formally integrated, DoD beneficiaries are seen by VA specialty providers and vice versa on a space-available basis. DoD beneficiaries therefore benefit from access to VA providers with specialties not present among Navy providers, including pulmonary critical care, infectious diseases, gastroenterology, nephrology, endocrinology, rheumatology, and hematology/oncology (Table 4-1). Veterans benefit from the access provided by the expanded clinical staffing. Navy inpatients and ED users also benefit from access to consultations from VA specialists (Interviews).

The pharmacy was designed to be integrated, where the DoD and the VA pharmacists could fill prescriptions for both TRICARE enrollees and veterans. This arrangement was dependent on an orders portability solution for pharmacy, which was not ready for use when the ACC opened and will not be ready until FY 2014, at the earliest. Instead, DoD pharmacists mostly serve TRICARE beneficiaries, using the DoD’s AHLTA, while the VA pharmacists mostly serve veterans, using the VA’s VistA.

Similarly, the efficiency of combining specialty clinics in the ACC on the west campus has been reduced by lack of interoperability between the two EHR systems. The plan was for clinical notes and information about laboratory tests, radiology, and prescriptions for recruits and other TRICARE enrollees seen in the ED and specialty clinics to be entered into VistA and for the information to be automatically populated in AHLTA. Quick, if not instant, entry into AHLTA is required because active duty servicemembers may be transferred on short notice and must take complete medical records with them. The information also might affect whether they are considered to be medically ready to be deployed. These capabilities were not ready for use when the ACC opened, necessitating the use of manual workarounds to duplicate the information entered into VistA into AHLTA, which has significantly affected productivity because of the increased paperwork load.

Conclusions Concerning Degree of Integration

The final organization of the FHCC displays various degrees of integration across services (see Table 4-2). Some services are VA only, such as long-term care and domiciliary, which only veterans can receive. Some are Navy only, such as the branch health clinics on the east campus that serve only active duty servicemembers. Inpatient mental health, medicine,

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