Transcript Document

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
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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The Pharmaceutical Care Team
3/22/2011
Management
Informaticist
Best Care
Any Where
Clinicians
Practice
Operations
3
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.
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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
• Education and Training
• Systems and Parameters
• Inventory Management
• Technician Training Modules
• Technician Forum
• Frequently Asked Questions
• Pharmacist Training Modules
• Event Planning
• Prime Vendor Group
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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 Pharmacy Informatics 101 – Basic FileMan
classes via LiveMeeting virtual
Pharmacy Informatics 102 – Basic MUMPS
Programming
sessions:
• IHS personnel are eligible to
attend
• Classes are typically capped at
~30 enrollees to encourage an
interactive environment.
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
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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 webbased 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.
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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 preand 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
Post-MOCHA
Post
PreExcluding
Including
CPRS v28
Type of Order Check
CPRS
Unable
to
Unable
to
/ Prev28
Perform
Perform
MOCHA
Alerts
Alerts
UNABLE TO PERFORM ORDER 0.00%
0.00%
0.00%
9.33%
CHECK*
ALLERGY-CONTRASTMEDIAINTER
0.01%
0.01%
0.03%
0.03%
LABORDERFREQRESTRICTIONS
0.43%
0.48%
0.56%
0.56%
RECENTBARIUMSTUDY
0.01%
0.01%
0.01%
0.01%
GLUCOPHAGE-CONTRASTMEDIA
0.06%
0.06%
0.07%
0.07%
ALLERGY-DRUGINTERACTION
2.16%
3.23%
3.69%
3.69%
DUPLICATEOPIOIDMEDICATIONS
0.76%
0.85%
0.95%
0.95%
BIOCHEMABNORMALITYFORCONT
0.36%
0.40%
0.43%
0.43%
GLUCOPHAGE-LABRESULTS
0.17%
0.21%
0.22%
0.22%
SIGNIFICANT DRUG INTERACTION*
7.91%
10.70%
10.68%
10.68%
AMINOGLYCOSIDEORDERED
0.01%
0.01%
0.01%
0.01%
DUPLICATEORDER
8.80%
13.66%
12.98%
12.98%
CRITICAL DRUG INTERACTION*
0.85%
1.16%
1.09%
1.09%
NOALLERGYASSESSMENT
0.33%
0.39%
0.34%
0.34%
DUPLICATE DRUG ORDER*
4.55%
6.33%
4.53%
4.53%
DUPLICATE DRUG THERAPY*
21.70%
27.81%
14.20%
14.20%
Total Order Checks
48.12%
65.32%
49.78%
59.11%
* Order Check Alert affected by MOCHA changes
% Change
from Preto PostMOCHA
N/A
81.36%
16.51%
15.98%
15.53%
14.04%
11.09%
6.77%
1.58%
-0.23%
-3.81%
-4.96%
-5.68%
-12.45%
-28.46%
-48.94%
-9.51%
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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
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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 Requests
http://vaww.national.cmop.va.gov/pre/NSR/Shared%20Docume
nts/Forms/AllItems.aspx?SortField=Modified&SortDir=Desc
• Program Enhancements – CPRS, Pharmacy VistA, BCMA
• Workgroups
–
–
–
–
Inpatient Medications
Pharmacy Legacy
BCMA
CPRS
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Pharmacy Legacy Enhancements FY12
“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
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ADMINISTRATION
Modification
to Pharmacy
Pkg to allow > 90 days fill
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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.
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EPCS – Electronic Prescripting
of 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
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FDA Medication Guides Project
• To Provide an automated distribution of Medication Guides, FDAapproved 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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The Way Forward
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The Way Forward
Legacy, 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
AViVA Technical
Framework
Migration
Presentation
Legacy
AViVA
User Application Platform
CPRS
CART
Care Plan
Med Rec
PHR
Epinome
etc.
My HealtheVet
Business Logic
VistA
Provider
packages
v1: Search service
Common Services
Population
Analytics
Order Integration
ADT
Patient
packages
Population
packages
etc.
VPHR
VPopR
Data
Local National
• Performs VPR queries
• Exposed as web services
v1: Virtual Patient Record (VPR)
• Unifying data model
• Informed by HiTSP standard
vx: MDWSx data extraction utilities
MDWSx
FileMan Data Files
• Indices optimized for clinical applications
• Lucene initiates Open Source model
v1: VPR Service
Terminology
Consistent Data Store
VPR
v1: Browser based Google-like search capability
• Simple, URL based model
• Baseline web infrastructure:
- Simplifies deployment
- Streamlines turnaround time
VINCI
CDW
DoD
Data
NwHIN
Data
• Merged AViVA-MDWS extraction services
• More complete, consistent data
• XML format
• Provides NwHIN extracts for VLER
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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
FY 11
FY12
FY13
FY14
FY15
iEHR
Candidate
Capability
Sets
1.0 Investment
Identify First Capability Set
Capability Set 1 Development
7-8 capabilities per Set
Set 2
Set 3
Set launched
every 6 months
Information Infrastructure Capability Set
Information Infrastructure
Capability Set
(Enabling Capabilities)
• GUI*
• SSO/CM
• Secure Messaging
o Provider-Provider
o Patient-Provider
• Identity Management Service
• Enrollment Eligibility
• Credentialing
• Terminology Service
• Orders Service
• Clinical Decision Support
(CDS)
• Security Messaging Service
FY16
Candidate Capability Set 1A
(Mature in CDF)*
Set 4
Sets 5-8
FY17
*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
• Framework
Sets 5-8
**Early in Capability Development
(Capability Set
1B) indicates that no development work has been completed
***Development and deployment of Pharmacy
capabilities will extend beyond Candidate Capability
Set 1A
Candidate Capability Sets 5-8
Candidate Capability Set 2
• Pharmacy***
o Inpatient
o Outpatient
o Medications
• Inpatient Documentation
o Allergies
• Outpatient Documentation
Candidate Capability Set 3
o CDS
• Anatomic Pathology
o Orders Fulfillment
• Radiology/Imaging
• Disability Evaluation
o Inventory Management
• Patient Portal Infrastructure
o Barcoding
• Anesthesia Documentation
o Orders Management
• Operating Room Management
o Mail Order
Candidate Capability Set 1B
Candidate Capability Set 4
• Immunization
(Early in CDF)**
• Dental Care
• Medical Device Management
• Emergency Department Care
• Registration
• Laboratory
• Disease Management
• Personal Health Record
• Disconnected Care
• Consult & Referral Management
• Care Management
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
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
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iEHR 2014 Snapshot
North Chicago
(VA, Navy)
Hampton Roads
(VA, Navy, Army, AF)
San Antonio
(VA, Army, AF)
years
FY2014
+
sites
+
Hampton Roads
San Antonio
clinical
capabilities
Laboratory
Immunization
+
North
Chicago
Pharmacy
Supporting Infrastructure
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Integrated Electronic Health Record
iEHR – 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
OR
Email: [email protected]
[email protected]
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