Transcript Department of Veterans Affairs, Office of Information Template

2010 … New Decade, New Tools
Pharmacy Informatics:
Out of the Silo, Into the Field
Rob Silverman, Pharm.D.
Program Manager, PBM
Clinical Informatics
[email protected]
April 28, 2010
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Objectives
• Describe the current state of the Class III
to Class I (C3>C1) Conversion Program
• Update the attendees on the status of
selected C3>C1 projects
• Collect ideas for continued improvements
to the conversion process
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Project List
• RobWare™
– Medication Reconciliation update
– Immunizations Documentation by BCMA
– Patients on Specific Drugs Multidivisional
Enhancements
– Inactivate [Pharmacy] Standard Schedule
– CPRS Lab Display Project
– Contingency Downtime Bookmark Progress Notes
– CWAD (Postings) Auto-Demotion
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Project List, continued
• Pharmacy-related
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–
–
–
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Anticoagulator
CPRS-PRN (Indications Required on Orders)
Drug File Price/Cost Last Updated
FileMan Function for Lab Results
Non-VA Medications Extract
• Other RobWare, not pharmacy-specific
– Default Encounter Location
– Health Summary Categorization
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Immunizations Documentation by BCMA
• Release Date: December 1, 2009
• Primary Function: Captures data for
immunizations administered to inpatients
that are recorded in BCMA. Creates an
entry in the Immunizations file for the
administrations if one is not already found
• Class III Lesson Learned: The place where
you store the data for a Class III project
may not be suitable for a Class I release
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Patients on Specific Drug(s)
• Release Date (projected): Feb 22, 2010
• Primary Function: Add multidivisional
support to an Inpatient Medications report
option, correct some bugs and defaults,
provide features for use of the VA Drug
Class hierarchy
• Class III Lesson Learned: The rules of the
conversion program are constantly
changing
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Medication Reconciliation
• Original Release Date: June 11, 2008
• Projected Patch Release Date: UNKNOWN
• Patch Purpose: Correction of bugs
(defects) with the original Class III to Class
I conversion
– This is not considered an “enhancements” project
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MedRecon Patch Bundles
• Patch “bundles” (my term…)
– PSO*7*316 and GMTS*2.7*92 – Tool #2
Medication Worksheet
– PSO*7*314 and GTMS*2.7*94 – Tool #1
Medication Reconciliation
– PSO*7*??? and GMTS*2.7*??? – Tools #3 and #4
Active/Pending/Expired Medications and Remote
Meds, Remote Allergies, plus Documentation
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MedRecon Lessons Learned
• This was the first program released
through the formalized Class III to Class I
conversion program
• It was not the first Class III software to
become part of a Class I release, however
• What got released had a very “Class III”
field-developed flavor to it
• The corrections will result in a MedRecon
program that is more consistent with the
rest of VistA Class I Software
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MedRecon Task Force & Workgroup
• And yet – this project still doesn’t change
the fact that they are just Health
Summaries (Reports), and we have many
other VHA initiatives about the broader
scope of Medication Reconciliation … just
ask Dr. Maureen Layden!
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Inactivate [Pharmacy] Standard Schedule
• What it does: Allows a site to mark
selected schedules from file #51.1
(ADMINISTRATION SCHEDULE) as
INACTIVE, thereby removing them from
display in the CPRS GUI drop-down
selection box
• What it doesn’t do: The current Class III
version does not impact backdoor orders,
existing orders, quick orders, nor provide
reports
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Inactivate Standard Schedule
• Current C3>C1 Status: Awaiting IDMC
Review
• Other discussions: Reviewed at Pharmacy
Legacy Quarterly Enhancements (PLQE)
User Group for consideration as an item
that may not have conflicts with Pharmacy
Reengineering routines
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CPRS Display of Lab Results
During Medication Ordering
• What it does: Display a relevant lab result
as part of the medication ordering screen,
similar to what the Pharmacy Action
Profile had in the days before CPOE
• What it doesn’t do: The current version
does not have support for multiple lab
tests to associate with a given drug file
item
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CPRS Lab Display
• Current C3>C1 Status: Awaiting HSC
presentation
• Notable Lessons Learned: One of the
major factors in the potential success of a
C3>C1 project is its impact on existing
Class I software.
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Change routines
Change files
Add routines only
Add routines and files
Combinations of the above…
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Contingency Downtime Bookmark
Progress Notes
• What it does: Sites can initiate a background
task to file a progress note “bookmark” to
indicate a period of time when the computer
was unavailable, as an explanation of why
some records might be delayed, scanned,
filed as paper, or otherwise difficult to find
• What it doesn’t do:
– Dishes
– Windows
– Self-demote from CWAD (Postings)  remember this!
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Downtime Progress Notes
• C3>C1 Status: Awaiting HSC presentation
• C3>C1 Process Notes:
– Several updates were requested by workgroups
reviewing the product, including multidivisional support,
features to file notes for clinic outpatients, improved
handling of a site’s default progress note text, and
better selection of patients admitted/discharged
immediately after the computer was restored
– The resulting product is a hybrid of programs originally
stable at Hines and Phoenix
– Each version had to be proven as stable and scalable,
with installation required to two (or more) production
accounts
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CWAD (Postings) Auto-Demotion
• What it does: A new entry for a Postings
(CWAD) note can replace the previous entry
of the same title in the Postings box
• What it doesn’t do: Other versions of this
Class III can demote a posting after the
passage of a fixed period of time
• How it works: The TIU “Change Title”
protocol is used to update a note from a
CWAD-hierarchy title to a non-Postings title
• Why it is useful: Keeps the content of the
Postings box clean, relevant and up-to-date
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CWAD Auto-Demotion
• C3>C1 Status: Awaiting HSC presentation
• Other factors:
– This will be a good partner program for the
Downtime Notes, as there is little value in filing the
entire VistA downtime history in postings, if a site
even chooses to categorize those notes as such
– The current Class III version still requires
programmer (@-sign) access, because it sets the
POST-SIGNATURE CODE for a TIU DOCUMENT
DEFINITION, which is a field restricted to
programmer editing only
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Anticoagulator
• Facility of Origin: Portland VAMC
• C3>C1 Status: As of Feb 2010, requesting
test site sign-off on T19 (test version #19)
• What it does: provides a tool for sites to
manage, track, and document use of oral
anticoagulation (i.e., warfarin)
• C3>C1 Process Notes: One of the key
factors in release of Class I software is to
eventually find a point at which the scope
definition is fixed, and any further
changes are limited to fixing defects,
without adding any enhancements.
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CPRS-PRN
(Indications Required on Orders)
• Facility of Origin: Portland VAMC
• C3>C1 Status: Awaiting revisions
• History:
– The original program was designed to require an
indication (entry into the Provider Comments field,
actually) for any item marked as PRN
– Upon review by the PBM program office, a request
was made to enhance the program to also engage
the same functionality for High-Alert medications
– Changes in support of the PBM office request
remain in progress
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CPRS-PRN
(Indications Required on Orders)
• Related work:
– New Service Request #20100101 is one of many
other requests, projects and opportunities to
address the continuing need for a method to place
indications as part of all prescription/medication
orders
– http://vista.med.va.gov/nsrd/Tab_GeneralInfoView.
asp?RequestID=20100101
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Drug File Price/Cost Last Updated
• Facility of Origin: Lincoln, NE > Omaha,
NE (Central Plains VA HCS)
• C3>C1 Status: ESM review completed,
awaiting IDMC review
• What it does: Adds a timestamp to the
drug file to indicate the last time when the
price field was updated
• C3>C1 consideration: current scope is for
a single field, may open discussions for a
more thorough multiple field to capture a
history
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FileMan Function for Lab Results
• Facility of Origin: Richmond VAMC, in
conjunction with the PBM MUMPS classes
• C3>C1 Status: In the ESM/RAEM Analysis
phase, HSC presentation to be scheduled
• What it does: allows addition of a lab
result as a FileMan field for any report
(Inquire or Print) that can reach the
PATIENT file
• C3>C1 Comments: although the process
is relatively slow, this request is
proceeding smoothly
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Non-VA Medications Extract
• C3>C1 Status: Feb 2010, beginning
analysis phase
• What it does: adds Non-VA medications as
a module within the standard monthly
PBM extract VistA application
• Why it’s important: although PBM can
access Non-VA meds data through the
Corporate Data Warehouse (CDW), this
format will give facilities and VISNs
access to their information for local use
just like is done currently with the
outpatient Rx extract module
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Default Encounter Location
• C3>C1 Status: IDMC approved, awaiting OED
technical review
• What it does: allows users to establish a list
of preferred encounter locations which will
then be displayed at the top of the selection
list in CPRS GUI
• C3>C1 Comments: while this program works
perfectly well, it requires the users (or an
administrator on their behalf) to perform the
setup in VistA. An ideal enhancement would
be to add the setup options directly within
CPRS GUI. Such a change is more difficult to
develop locally, however, because the CPRS
application is a single-compiled executable
program
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Health Summary Categorization
• C3>C1 Status: IDMC approved, awaiting OED
technical review
• What it does: The current display of Health
Summaries in CPRS is manually sequenced by
the CAC or HS manager. This program creates
categories of Health Summary Types, which are
artificially alphabetized and sorted during the
display process
• C3>C1 Comments: Like other programs noted,
the setup is within the VistA application, and as
written, overrides a user’s health summary
customization. The advantages in locating a
selected HS within a large list (often 100+ reports)
has proven to offset the loss of functionality to
individually assign reports to selected users.
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Conclusions
1. The process is slow, but has been
successful
2. Requirements of defining the scope of a
program are intended to avoid the
“never-ending project”, not to prohibit
improvements during Class I conversion,
especially when required by SAC
(Standards and Conventions)
3. This presentation likely only scratches
the surface of important innovative ideas
within VA
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