5 th Annual PBM Pharmacy Informatics Conference

1. 5th Annual PBM Pharmacy Informatics Conference VHA Pharmacy Informatics State of the Union Lynn C. Sanders, PharmD Associate Chief Consultant Pharmacy Benefits Management June 06 2012

2. 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

3. 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

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.

6. 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

7. 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 Group

8. 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

9. 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 Programming Pharmacy Informatics 103 – Basic VBA Macros for Reflections Pharmacy Informatics 104 – Basic SQL Queries Pharmacy Informatics 201 – Intermediate FileMan Pharmacy Informatics 202 – Intermediate MUMPS Programming Pharmacy Informatics 301 - FileMan Advanced

10. 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.

11. 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

12. 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

13. 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.

14. 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)

15. Pharmacy Reengineered System

16. 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

17. 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

18. Pharmacy Re-engineering Benefits Realization Measuring Success of MOCHA

19. 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%.

20. 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).

21. 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.

23. Methods to Improve Software Development and Implementation at VAMCs – Lessons Learned • 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 rides • Customization of Commercial Data Systems such as First DataBank is critical to manage drug information and order checking. PBM PECS Customization System

24. 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.

25. Pharmacy Legacy Enhancements • National Drug File Management and Patch Releases • Updates to the Legacy Systems

26. VistA Legacy Enhancements • New Service Requests http://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

27. Pharmacy Legacy Enhancements FY12

28. 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

29. PBM Notice • 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.

30. 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 Cards

31. 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.

32. State Prescription Drug Monitoring Program (PDMP) • VA is working to develop a system/tool to participate in controlled substances data sharing state monitoring program.

33. The Way Forward

34. 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

35. Pharmacy Reengineered System

36. AViVA Technical Framework AViVA Technical Framework Migration Legacy AViVA • v1: Browser based Google-like search capability • Simple, URL based model • Baseline web infrastructure: • - Simplifies deployment • - Streamlines turnaround time CPRS My HealtheVet User Application Platform Care Plan Med Rec CART Presentation PHR Epinome etc. VistA Common Services • v1: Search service • Indices optimized for clinical applications • Lucene initiates Open Source model Population Analytics Order Integration Provider packages • v1: VPR Service • Performs VPR queries • Exposed as web services ADT Terminology etc. Patient packages Business Logic • v1: Virtual Patient Record (VPR) • Unifying data model • Informed by HiTSP standard Consistent Data Store VPR VPHR VPopR Population packages • vx: MDWSx data extraction utilities • Merged AViVA-MDWS extraction services • More complete, consistent data • XML format • Provides NwHIN extracts for VLER MDWSx VINCICDW NwHIN Data DoD Data FileMan Data Files Data Local National

37. 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”

38. iEHR “To Be” Architecture

39. iEHR Candidate Capability Sets • *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 Capability Set 1 Development Sets 5-8 Set 4 Set 3 Set 2 Identify First Capability Set 7-8 capabilities per Set Information Infrastructure Capability Set Set launched every 6 months Sets 5-8

40. iEHR 2014 Snapshot North Chicago (VA, Navy) Hampton Roads (VA, Navy, Army, AF) San Antonio (VA, Army, AF) 2 2 2 1 + + + years sites clinicalcapabilities North Chicago FY2014 Hampton Roads San Antonio Laboratory Immunization Pharmacy Supporting Infrastructure

41. Integrated Electronic Health RecordiEHR – 2+2 • iEHR San Antonio, Hampton Roads – Presentation Layer/User Experience integration with DoD and VA Legacy Systems – GOTS • Willdemonstrate the power of iEHR‘s multipurpose, modular components to better supportoutpatient primary care at Hampton Roads and San Antonio by end of FY2014. Functionalitywill include a new,common user interface for managing documentation, laboratorytest, 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

42. QUESTIONS? Please use the Q&A Function on Live Meeting OR Email: Rosemary.Grealish@va.gov Debra.Macdonald@va.gov