5 th Annual PBM Pharmacy Informatics Conference VHA Pharmacy Informatics State of the Union June 06 2012 Lynn C. Sanders, PharmD Associate Chief Consultant

5th Annual PBM Pharmacy Informatics Conference

VHA Pharmacy Informatics State of the Union

June 06 2012

Lynn C. Sanders, PharmDAssociate Chief Consultant

Pharmacy Benefits Management

VETERANS HEALTH ADMINISTRATION

Who Are We?

Lynn Sanders – PBM Associate Chief Consultant for Clinical Informatics/Pharmacy Re-engineering

– Adelaide Quansah– TaKia Dunn

LuAnne Barron – Program Manager – Pharmacy Re-engineering/iEHR– Amy Colon – Clinical Analyst– Mike Martinko – Clinical Analyst

Robert Silverman – Program Manager – Clinical Informatics and Education and Training/Immunizations-iEHR

Program Specialist – Education and Training (Vacant)Pharmacy Informatics Field Advisory Task Force– Tom Fagan – Education and Training

Don Lees – Program Manager – Pharmacy Enterprise Product System and National Drug File Management

– Deborah Coulter – Program Specialist– Todd Schippers – Program Specialist– Oliver Havens – Clinical Analyst

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Top Priorities• Re-engineering and Enhancement of Pharmacy Information

System to improve patient safety, efficiency, and care to Veterans

• Provide communications and support to VAMC pharmacies with informatics and analytics information, problem resolution, and education and training.

• Professional Development for VA Pharmacy Informaticists (Pharmacists and Technicians)

• Identify and Support processes to improve workflow• Represent PBM as the business owner in relationships within

VA (VA IT and VHA Health Information Offices) and nationally.• iEHR Pharmacy Solution

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Management

Informatic ist

Clinic ians

Practice Operations

3/22/2011

The Pharmaceutical Care Team

Best CareAny Where

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VETERANS HEALTH ADMINISTRATION 5

ASHP Definition of Pharmacy Informatics

• A pharmacy informaticist is a dedicated specialist involved in the computerization and automation of the medication use process.

• Pharmacy Informatics is the use of integration of data, information, knowledge, technology, and automation in the medication use process for the purpose of improving health outcomes.


VA Pharmacy Informaticist

Responsibilities– Implementation/ monitoring/reporting of/for VistA and VistA

interfaced systems– Maintenance and support of pharmacy automated dispensing and

storage systems– Subject Matter and Knowledge Experts for Pharmacy Information

Systems– Testing VistA Software for Pharmacy (patches)– Communicating with local IT staff– Communicating with PBM Clinical Informatics/PRE staff– Reporting system defects (remedy) and patient safety concerns to

VA IT.– Participating in training and education

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PBM Pharmacy Informatics Advisory Task Force

• Automation and Technology

• Systems and Parameters

• Technician Training Modules

• Frequently Asked Questions

• Event Planning

• Education and Training

• Inventory Management

• Technician Forum

• Pharmacist Training Modules

• Prime Vendor Group7


Objectives of Pharmacy Informatics Education in VA

• To identify and analyze the current state of informatics education

• To identify current competencies in informatics education

• Develop a core set VA pharmacy informatics training modules

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Education and Training

• As of FY12, PBM now offers these classes via LiveMeeting virtual sessions:

• IHS personnel are eligible to attend

• Classes are typically capped at ~30 enrollees to encourage an interactive environment.

Pharmacy Informatics 101 – Basic FileMan Pharmacy Informatics 102 – Basic MUMPS ProgrammingPharmacy Informatics 103 – Basic VBA Macros for ReflectionsPharmacy Informatics 104 – Basic SQL Queries

Pharmacy Informatics 201 – Intermediate FileMan Pharmacy Informatics 202 – Intermediate MUMPS Programming

Pharmacy Informatics 301 - FileMan Advanced

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Web Based Pharmacy Informatics Course – Partnering with Health Informatics

• The Department of Veterans Affairs (DVA) Pharmacy Benefit Management (PBM) Office of Clinical Informatics, in collaboration with the VHA Employee Education System (EES) and the Health Informatics Initiative in the Office of Informatics and Analytics, is in the process of producing web-based pharmacy informatics course(s) for training and development of Pharmacists and Pharmacy Technicians in the field of informatics.

• When complete, the course(s) will be available as an educational benefit to VA employees and other identified federal agencies.

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Working with Other PBM Offices, VPEs, and Medical Centers

• Pharmacy Technician Roles in VHA• Establishing policies for informatics – system access,

functional statements• PACTS and pharmacy staff access to meeting patient needs

through My HealtheVet• VISN Pharmacy Executives for formulary and drug file changes

– NDF Updates• E-Pharmacy Claims

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Working with the Office Health Informatics and Office of Information and Analytics

• Health Systems Management Office– Liaison to VA OIT

• Analysis of New Service Requests• Project Funding• Prioritization of Projects

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Why Was the Initiative Created?

“Transform Healthcare Delivery through Health Informatics” (Health Informatics Initiative or hi2) was created by Secretary Shinseki in May 2010 with these missions:

• Provide foundational IT and Informatics components for VHA’s transition

from a medical model to a patient-centered model of care.

• Build a sustainable collaborative approach, capacity, and tools to

deliver informatics solutions to transform

health care delivery to Veterans through

three major projects or Workstreams.


Working with Organizations to Develop Informatics Systems for Pharmacy Terminology and Process Modeling

• FHIM Modeling Group - Modeling• NCPDP – Terminology and Modeling• ONC – Office of National Coordinator for Health IT -

Terminology, Modeling, Coding• RxNorm – National Library of Medicine – Terminology and

Coding• CHDR for mapping VA and DoD Terminology and Codes

(includes 3Ms HDD Terminology Service)

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Pharmacy Reengineered System

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PRE – Re-engineering VistA

• Transitioning from local VistA to an Enterprise System – the concept of One VA

• No longer requiring local drug file updates of drug content and information but a PUSH out from national that would provide daily updates supporting all VistA modules that use the VA Drug file for ordering, patient care, and financials.

• Improves Patient Care reduces potential ADEs due to delays in updating Drug File information

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Pharmacy Re-engineering FY12/13

• PECS – Pharmacy Customization• MOCHA – Medication Order Check Healthcare

Application – Interactions Enhancements and Dosing• PPSN – Pharmacy Product System National• PPSL – Pharmacy Product System Local

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Pharmacy Re-engineering Benefits Realization

Measuring Success of MOCHA


Patient Safety:

• It is proven that the functionality of the PRE project directly and immediately impacts the care of Veterans. An increase in clinical support tools, along with improvements to the content of drug file data at the enterprise and VA Medical Center levels will significantly prevent the negative and costly impact of patient harm from ADE’s. As a result of the beta test implementation of MOCHA v1.0 and v2.0, at a typical VA Medical Center in 2010, the yearly rate of reported ADE’s pre- and post-installation were reduced by 56%.

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Costs:

• The costs of Adverse Drug Events (ADE) have been reported to be approximately $4,600 per event (non-death) in an Agency for Healthcare Research and Quality Report. PRE has already reduced ADEs by 56% at one VAMC that has implemented both Drug Interactions and Dosing order checks. This could represent a cost avoidance of $1,354,976 per year if similar results are seen for all VAMC’s (526 PRE Preventable ADEs Reported in 2008).

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MOCHA Impact on Workflow

• Workflow:• Reports from five facilities using PRE MOCHA v1.0 indicate

that targeted order check pop-up alerts have decreased by 32%, improving the quality of clinical decision support information while reducing potential provider and pharmacist pop-up alert desensitization.

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Figure 1. Order Check Types as a Percentage of New Orders

Type of Order Check Pre-

CPRS v28

Post CPRS v28

/ Pre-MOCHA

Post-MOCHA % Change from Pre- to Post-MOCHA

Excluding Unable to Perform Alerts

Including Unable to Perform Alerts

UNABLE TO PERFORM ORDER CHECK*

0.00% 0.00% 0.00% 9.33% N/A

ALLERGY-CONTRASTMEDIAINTER 0.01% 0.01% 0.03% 0.03% 81.36%

LABORDERFREQRESTRICTIONS 0.43% 0.48% 0.56% 0.56% 16.51%

RECENTBARIUMSTUDY 0.01% 0.01% 0.01% 0.01% 15.98% GLUCOPHAGE-CONTRASTMEDIA 0.06% 0.06% 0.07% 0.07% 15.53%

ALLERGY-DRUGINTERACTION 2.16% 3.23% 3.69% 3.69% 14.04% DUPLICATEOPIOIDMEDICATIONS 0.76% 0.85% 0.95% 0.95% 11.09%

BIOCHEMABNORMALITYFORCONT 0.36% 0.40% 0.43% 0.43% 6.77%

GLUCOPHAGE-LABRESULTS 0.17% 0.21% 0.22% 0.22% 1.58% SIGNIFICANT DRUG INTERACTION* 7.91% 10.70% 10.68% 10.68% -0.23%

AMINOGLYCOSIDEORDERED 0.01% 0.01% 0.01% 0.01% -3.81%

DUPLICATEORDER 8.80% 13.66% 12.98% 12.98% -4.96% CRITICAL DRUG INTERACTION* 0.85% 1.16% 1.09% 1.09% -5.68%

NOALLERGYASSESSMENT 0.33% 0.39% 0.34% 0.34% -12.45%

DUPLICATE DRUG ORDER* 4.55% 6.33% 4.53% 4.53% -28.46% DUPLICATE DRUG THERAPY* 21.70% 27.81% 14.20% 14.20% -48.94%

Total Order Checks 48.12% 65.32% 49.78% 59.11% -9.51%

* Order Check Alert affected by MOCHA changes

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Methods to Improve Software Development and Implementation at VAMCs – Lessons Learned

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Preparation - Bridge gap between technical application and operational execution – working directly with medical centers, assessing CPRS and VistA local system parameters set up prior to implementing new enterprise level software – Site Visits

Training and Communications – Develop and make available training programs for new systems that include technical and business process changes and maintenance and support requirements. Web Based, easy access

Processes – Build new business processes (policies and procedures) that incorporate new technologies. Define and obtain resources to support new technologies. Review Staffing and Procedures

Balance Clinical Information – Oder Checks, Alert Fatigue, Information of value that has a direct impact on the care of the patient. Access impact of new order check over ridesCustomization of Commercial Data Systems such as First DataBank is critical to manage drug information and order checking. PBM PECS Customization System


The MOCHA Survey

Product Effectiveness (PE), in support of the Pharmacy Benefit Management (PBM) team, is planning to deploy a nationwide survey to Pharmacists at all VA Medical Centers that have received the VistA Pharmacy MOCHA v 1.0 order check enhancements. This web-based survey is currently planned for deployment around May of 2012. The goal of the survey is to gather information regarding the end-user experience with this initial implementation of MOCHA to quantitatively understand to what degree the intended benefits of the enhancements have been realized.

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Pharmacy Legacy Enhancements

• National Drug File Management and Patch Releases

• Updates to the Legacy Systems

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VistA Legacy Enhancements

• New Service Requestshttp://

vaww.national.cmop.va.gov/pre/NSR/Shared%20Documents/Forms/AllItems.aspx?SortField=Modified&SortDir=Desc

• Program Enhancements – CPRS, Pharmacy VistA, BCMA• Workgroups

– Inpatient Medications– Pharmacy Legacy– BCMA– CPRS

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http://vaww.national.cmop.va.gov/pre/NSR/Shared%20Documents/Forms/AllItems.aspx?SortField=Modified&SortDir=Desc




Pharmacy Legacy Enhancements FY12

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“Medication Profile and Refill” HRC CAPRI Enhancement,

Drug Enter/Edit IV Mismatch

Titrations of maintenance dose

CMOP rejecting scripts with long directions.

Adjustment of Expiration date

Order checks against expired meds

Med Route Selection - will be addressing OP and IM after MOCHA 1 and 2 are released.

1.HOLD/UNHOLD for Pharmacy Techs 2. Adding additional hold reasons and displaying the hold reasons through out the application

Validate Termination of a Provider.

Inpatient Medications HD129134 (HD147086, PSI-06-015/PSPO#276) - DOSAGE

Possible Dosage and Local Possible Dosage Display

A PSO Patch to address changes in PSS*1*78

Modification to Pharmacy Pkg to allow > 90 days fill


PBM Reviews and Endorses VistA Patches to Correct Defects

• VHA has obtained the necessary signatures and approvals to release the following:

• RR12-00243 (PSJ*5*277) - This Pharmacy - Inpatient Medications patch resolves a problem in which the Expected First Dose line in the Computerized Patient Record System (CPRS) and the REQUESTED START DATE line in Inpatient Order Entry are not displaying the correct date.

• Defect Received May 9, 2012 • Patch Approved for IOC Testing May 24, 2012

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• Incorrect Outpatient Prescription Last Fill Date after Date of Death marked “Entered in Error”

• Distribution Date: August 16, 2011• Notice Number PBM-2011-03 • SUBJECT: • Incorrect Outpatient Prescription Last Fill Date after Date of Death marked

“Entered in Error”• APPLICATIONS AFFECTED:• Outpatient Pharmacy v7.0• ATTENTION:• Pharmacy Chiefs• Pharmacy ADPACS• Pharmacy Outpatient Supervisors• Please share this Notice with Outpatient Pharmacy staff at your facility.

PBM Notice

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EPCS – Electronic Prescriptingof Controlled Substances

• DEA regulations effective June 2010 to permit ePrescribing of Controlled Substances

• VA will introduce features for EPCS with CPRS v29• Initial Operating Capacity (IOC) testing projected for

July/August 2012• National Deployment anticipated by end of CY 2012• Key Points to the Prescribers

– ALL SCHEDULES of controlled substances, not just C-II– Using VA Personal Identity Verification (PIV) ID Badges / Smart

Cards30


FDA Medication Guides Project

• To Provide an automated distribution of Medication Guides, FDA-approved patient information, with every fill for selected prescription drugs that pose a serious and significant public health concern.

• The list of medications needing Medication Guides continues to grow and manual processes are no longer sufficient to ensure that patients receive this valuable information.

• FDA Medication Guides Increment #3 was nationally released on March 27, 2012

• One “accepted” risk/issue is that since Rx labels print from VistA, and Med Guides print via a Java Server, if a site elects to print them to the same physical printer, even using two separate paper trays, network traffic cannot guarantee perfect collation.

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State Prescription Drug Monitoring Program (PDMP)

• VA is working to develop a system/tool to participate in controlled substances data sharing state monitoring program.

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VETERANS HEALTH ADMINISTRATION The Way Forward 33


The Way ForwardLegacy, PRE, and iEHR

• Past - VistA• Present – PRE and Continued investment in Legacy

systems – CPRS, Pharmacy, BCMA, Lab• HI2/AVIVA • OSHERA – Open source development efforts

– http://www.osehra.org/

• Future – iEHR 2017

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Pharmacy Reengineered System

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AViVA Technical Framework

User Application Platform

Common Services

Consistent Data Store

CART Care Plan

Population Analytics

VPR

etc.

etc.

DoD Data

NwHINData

AViVA

VistA

Providerpackages

CPRSMy HealtheVet

Med Rec

PHR

Migration

v1: Browser based Google-like search capability• Simple, URL based model• Baseline web infrastructure:

- Simplifies deployment - Streamlines turnaround time

ADT Terminology

Order Integration

VPHR VPopR

MDWSx

VINCICDW

Pre

sent

atio

nB

usi

ness

Lo

gic

Dat

a

Legacy

FileMan Data FilesLocal National

Patientpackages

Populationpackages

Epinome

v1: Search service • Indices optimized for clinical applications• Lucene initiates Open Source model

v1: VPR Service• Performs VPR queries• Exposed as web services

v1: Virtual Patient Record (VPR)• Unifying data model• Informed by HiTSP standard

vx: MDWSx data extraction utilities• Merged AViVA-MDWS extraction services• More complete, consistent data• XML format• Provides NwHIN extracts for VLER

AViVA Technical Framework


Integrated Electronic Health Record - iEHR

• “Secretary Shinseki described the integrated Electronic Health Record, or iEHR, as ―one that is open in architecture and nonproprietary in design to expand information sharing, eliminate gaps between our two (DoD and VA) robust health care systems…This is key to seamlessness, critical to enhancing quality of health care, and essential to controlling costs”

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iEHR “To Be” Architecture

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iEHR Candidate Capability Sets

• Sets 5-8

Candidate Capability Set 1A (Mature in CDF)*

• Pharmacy***o Inpatiento Outpatiento Medicationso Allergieso CDSo Orders Fulfillmento Inventory Managemento Barcodingo Orders Managemento Mail Order

• Immunization• Dental Care

Candidate Capability Set 2

• Inpatient Documentation• Outpatient Documentation• Anatomic Pathology• Disability Evaluation


• Radiology/Imaging• Patient Portal Infrastructure• Anesthesia Documentation• Operating Room Management


• Medical Device Management• Registration• Disease Management• Disconnected Care

Candidate Capability Sets 5-8

• Business Intelligence• Scheduling Appoint• Patient Questionnaire• Patient Consent• Patient Education• Alerts and Reminders• Patient Self Report• DoD/VA Registries• NCAT (TBI Testing)• Global Image Access• Patient Safety Reports• Teleconsultation• Document Management• Blood Management• Private Sector Data Access• Nutrition Care• XML Forms Tool• Utilization Management• Genomics• Encounter Coding

Candidate Capability Set 1B(Early in CDF)**

• Emergency Department Care• Laboratory• Personal Health Record• Consult & Referral Management• Care Management

Information Infrastructure Capability Set

(Enabling Capabilities)

• GUI*• SSO/CM• Secure Messagingo Provider-Providero Patient-Provider

• Identity Management Service• Enrollment Eligibility• Credentialing• Terminology Service• Orders Service• Clinical Decision Support

(CDS)• Security Messaging Service

*Mature in Capability Development Framework (Capability Set 1A) indicates that some work has been completed toward capability delivery (e.g., teams have been formed to review clinical workflows and develop requirements for these workflows

**Early in Capability Development Framework (Capability Set 1B) indicates that no development work has been completed

***Development and deployment of Pharmacy capabilities will extend beyond Candidate Capability Set 1A

FY 11 FY12 FY13 FY14 FY15 FY16 FY17

1.0 Investment

Set launchedevery 6 months

Identify First Capability Set7-8 capabilities per Set

Sets 5-8Set 4

Set 3Set 2

Capability Set 1 Development

Information Infrastructure Capability Set

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San Antonio(VA, Army, AF)

Hampton Roads(VA, Navy, Army, AF)

North Chicago(VA, Navy)

2 years 2 sites 2 clinicalcapabilities 1North

Chicago+ + +FY2014 Hampton Roads

San AntonioLaboratory

ImmunizationPharmacy

Supporting Infrastructure

iEHR 2014 Snapshot


Integrated Electronic Health RecordiEHR – 2+2

• iEHR San Antonio, Hampton Roads – Presentation Layer/User Experience integration with DoD and VA Legacy Systems – GOTS – Will demonstrate the power of iEHR‘s multipurpose, modular components

to better support outpatient primary care at Hampton Roads and San Antonio by end of FY2014. Functionality will include a new, common user interface for managing documentation, laboratory test, medications, and immunizations.

– PBM recommends that the iEHR Pharmacy Capability be included here.

• iEHR Pharmacy – JALFHCC 2014– A COTS System

• Medication Ordering/Prescriptions Using CPOE and Clinical Decision Support for • Inpatient and Outpatient Medication Orders and Prescriptions Fulfillment• Inventory

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QUESTIONS?

Please use the Q&A Function on Live Meeting

OREmail: [email protected]

[email protected]

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mailto:[email protected]

mailto:[email protected]