The CAPT James A. Lovell Federal Health Care Center:

1. The CAPT James A. Lovell Federal Health Care Center: Presented By: Jennifer Hirsh, PharmD Kay Willis, RPh Aug 2011 It Takes a Whole LOT of Apps For That!

2. Objectives • Understand pre-merger Pharmacy operations at the Naval Hospital Great Lakes and North Chicago VA Hospital. • Compare and contrast pre- and post-merger workflows. • Recognize challenges involved in merging DoD and VA pharmacy operations. • Gain information regarding the use of IT in a merged VA/DoD pharmacy.

4. Timeline of a VA/DoD Merger

5. Phase 2

6. Phase 3

7. Phase 4

8. Phase 5

10. Picturefrom: http://www.lovell.fhcc.va.gov/

11. Executive Decision Memorandums • CMOP for DoD Beneficiaries • Formulary • Physical Design • Prime Vendor

12. Medium Rocks • Computer System—IM/IT group working on it. We will adapt to whatever computer system is selected • Electronic C-II Prescribing • Inventory Control • Controlled Substance Inventories • Controlled Substance Rules • Non-formulary process • Line-item Extension/Tablet-Splitting • Smoking Cessation Program • Medication Error Reporting System and ADE: • VA reports medication errors to NCPS • Navy reports medication errors to BUMED • X • Medication Error Reporting System and ADE: • VA reports medication errors to NCPS • Navy reports medication errors to BUMED • X

13. Pre-Merger Workflow • DoD: Utilizes ScriptPro SP200 and QMatic • Bank teller concept outpatient windows • VA: Automed and other systems • Double queue concept outpatient windows

14. Pharmacy Merger: By the Numbers • 7 Pharmacy sites • 130+ staff members • 2 pharmacy processing systems (CHCS/VISTA) • 2 electronic health records (AHLTA/CPRS) • 2 networks (East and West Campus) • 2 formularies • 3 patient queuing systems • 2 telephone refill systems • 3 door access and alarm systems • 4 ScriptPro filling robots with 42 RCM cells • 33 ScriptPro verification terminals • 6 CII Safes • Pyxis machines • 1 Pharmacy Informaticist and 1 VISN 12 Pharmacy Consultant=Priceless

15. Challenges Staff Training Two Pharmacy Systems Two Formularies Reporting Requirements Workflow From imdb.com

16. Challenges • Required to maintain 2 separate pharmacy processing systems (CHCS/VISTA) hosted on two servers in conjunction with two electronic health records. • Must adhere to 2 separate formularies based on patient eligibilities (VA/DoD/Dual Consumer). • Short time frame and limited resources inhibited ability to provide in-depth hands-on cross-training of staff prior to merger. • Pre-merger workflow models did not meet the new mission of a combined DoD/VA healthcare facility.

17. Challenges • Must be able to maintain separate workload reports and inventory utilization reports for each beneficiary group. • Ensure maximum patient safety while maintaining efficiency standards in prescription processing, filling and dispensing. • Workload from two pharmacies combined into one pharmacy with only a modest increase in space.

18. Staff Training • FHCC Outpatient Pharmacy uses both CHCS and VISTA pharmacy processing systems. Inpatient Pharmacy uses VISTA for inpatients, CHCS or VISTA for discharges. • Pharmacy Informaticist developed a 2-hour “Introduction to VA Pharmacy” presentation +Q&A session which was presented to DoD staff members by Pharmacy Informaticist and two VA volunteers. Presentation covered basic eligibility info, workflow, co-pays, etc. • PBM Informatics group provided additional VISTA Pharmacy menu step-by-step training PowerPoints as well as two “over-the-shoulder” trainers to provide a week of in-depth hands-on training.

19. Staff Training • The DoD provided a series of two hour CHCS Pharmacy training sessions for VA staff. VA pharmacy staff members with knowledge of CHCS provided additional support and references. • A Department SharePoint site was developed by the Pharmacy Informaticist to provide continued training and reference materials for hospital staff.

20. Staff Training

21. Patient Queuing System • A touch screen patient queuing system (Q-Flow) was installed in order to filter patients by eligibility/priority category. • Categories include: DoD, VA, Active Duty in Uniform and ER/Discharges. • Has since evolved into a combined VA/DoD category. • System is multi-purpose: • Serves as patient-run queuing/ticketing system. • Captured initial basic patient population and wait time data. • Allows pharmacy supervisors to control number of windows open for each patient category based on need . • Provided staff members additional time to cross-train on processing systems (CHCS/VISTA). • Linked to television screens, provides patients updates on pharmacy department news.

22. Patient Queuing System Insert lovell screenshot here

23. Patient Queuing System

24. Patient Queuing System

25. Pharmacy Processing Systems • Pharmacy Informaticist maintains two separate pharmacy systems/drug files. • To assist staff with transition, worked to standardize drug file entries between two systems. • Inactivated outdated entries. • Adjusted nomenclature to match RX Norm/CMOP . • Entered additional messages/comments to drug file entries to assist with unit of use differentiation. • Mapped entries across both systems in order to develop a basic formulary.

26. Pharmacy Processing Systems WEST CAMPUS EAST CAMPUS

27. Pharmacy Processing Systems

28. Pharmacy Processing Systems

29. Barcode Automation System • A barcode-driven filling/verification/dispensing system (ScriptPro) was installed in 3 pharmacy areas (Oct-Dec) and 2 additional areas this July. • System receives inputs from both VISTA and CHCS via two HL7 interfaces connecting to one filling robot IP per site. • Both interfaces require linkage of label printer.

30. Barcode Automation System

31. Barcode Automation System Lovell Mail Out Share patient dispensing profiles and use of robot filling Burkey Mall Refills filled by Fisher robot Lovell Outpatient Share patient dispensing profiles Refills filled by Fisher robot Lovell Inpatient Discharges Fisher Clinic

32. Barcode Automation System • Multi-purpose system: • Barcodes required to fill and verify prescriptions (helps staff differentiate between products/increases patient safety). • Allows shift of workload between sites: • To satellite pharmacy robot/staff for completion of DoD refills. • From Mailout Pharmacy for completion of building patient batches. -Reduces extra steps in workflow. -Release notification sent back to VISTA automatically. -Controlled substance signature log now electronic. -Reduces number of label reprints and partials. -Serves as pharmacy downtime system during system/network outages. -Provides valuable reporting tools.

33. Barcode Automation System • Customized reporting tools include: • Patient census data based on source interface (# of VA vs DoD beneficiaries and # of prescriptions) • Workflow processing time data (receipt of prescription by automation until dispensing) • Drug utilization reports by site and beneficiary category (VA/DoD) to assist with procurement, stock areas and future financial reconciliation. • Controlled substance signature/receipt logs.

34. Barcode Automation System

35. Formularies • Per the merger EDM, the combined FHCC pharmacy is required to maintain two formularies: the VA National Formulary and a hybrid DoD/VA formulary. • Over 500 new line items (medications and supplies) were added to the DoD formulary. • Pharmacy Informaticist has worked with LexiComp to develop two online searchable formulary tools: outpatient network prescriptions and in-house provider.

36. Formularies

37. Conclusion • Merging two federal health care systems across two servers presents significant challenges and requires changes in workflow to meet the new joint mission. • Multiple “workarounds” have been developed to overcome said challenges. • IT systems and “apps” have shaped the workflow of Pharmacy operations and provided significant reporting capabilities.

38. References and Acknowledgements • Cartoons provided by Ron Parker • Lovell FHCC picture from: http://www.lovell.fhcc.va.gov • Formulary splash page developed in conjunction with Lexi-Comp. • Patient Queuing System screenshot and cartoon from Q-Flow. • Special thanks to the PBM Informatics Team for providing VISTA training documents and trainers (Shirley, Nancy and Kay) for the Lovell FHCC Pharmacy Staff.