VHA's educational mission is to ensure an adequate supply of clinical care and allied health providers for veterans and the nation. VHA facilities train more than 100,000 individuals from more than 40 health professions every year. VHA directly funds approximately 9,000 physician residency positions and 10 percent of the nation's graduate medical trainees. It is also affiliated with 105 of the nation's 126 medical schools, training 22,000 medical students for at least part of their clinical rotations every year (Kizer, 1997). In addition, the number of ambulatory-care VHA training sites is increasing, providing opportunities not often found at academic health centers.
The sheer number of trainees allows VHA to have a tremendous impact on future medical practice, an impact that is unparalleled by that of any other health care organization in the nation. In addition, the resources at VHA can produce reference manuals and guidebooks that smaller organizations cannot easily provide. One example relevant to infectious disease is the Emerging Pathogens Guidebook. This volume, which serves both as a reference for current practitioners and as a textbook for a workshop in the year 2000, is intended to assist in the prevention of the spread of infectious diseases. In addition, the guidebook serves to provide information and guidance to DVA health care teams. The teams can then modify their health care workplaces to improve infection control practices and minimize the occurrence of nosocomial infections.
The DVA National Formulary, adopted on June 1, 1997, is meant to provide better patient care at a lower cost. Before that date, each VISN was responsible for maintaining its own formulary and making all formulary decisions. The change to the national formulary instituted a tiered system, splitting the decision making process between VHA's Pharmacy Benefits Management Strategic Healthcare Group, each individual VISN, and each facility within a VISN. Each VISN maintains a formulary that provides at least all the drugs on the national level, and facilities maintain formularies that provide at least all the drugs on the VISN and national levels. The tiered system works in conjunction with an ''open" and "closed" drug classification system.
When VHA has secured a national contract with a drug manufacturer to provide particular pharmaceuticals, the drugs are considered to be in "closed" drug classes. In this case, individual VISNs or facilities cannot add additional pharmaceuticals to the formulary. Non-formulary drugs can be prescribed through a procedure used to identify unique clinical circumstances that warrant the use of nonformulary prescriptions, such as the therapeutic failure of all existing formulary pharmaceuticals. The four classes of drugs characterized as "closed" are proton pump inhibitors, alpha-blockers, HMG coeneyme A reductase inhibitors, and angiotensin-converting enzyme inhibitors.