Who Are We?

1. Pharmacy Benefits Management Clinical Informatics and Pharmacy Re-engineeringStrategic InitiativesLynn C. Sanders, Pharm D.Associate Chief Consultant PBM Clinical Informatics/Pharmacy Re-engineering

2. Who Are We? Lynn Sanders – PBM Associate Chief Consultant for Clinical Informatics/Pharmacy Re-engineering Adelaide Quansah LuAnne Barron – Program Manager – Pharmacy Re-engineering Amy Colon – Clinical Analyst Mike Martinko – Clinical Analyst Al Havens – Clinical Analyst Robert Silverman – Program Manager – Clinical Informatics and Education and Training 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 2

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. Represent PBM as the business owner in relationships within VA (VA IT and VHA Health Information Offices) and nationally. iEHR Pharmacy Solution 3

4. PBM Clinical Informatics Relationship with the Field

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. 5

6. What’s a Pharmacy Informaticist/ADPAC Directive Requirements for minimum local IT system access • VistA menus • FileMan files required by the Pharmacy Informaticist and VistA access required of any service ADPAC but not specific to pharmacy. • Any VistA Security Keys that are required to access VistA options required by this directive. 6

7. 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

9. PBM Pharmacy Informatics Advisory Task Force • Automation Technology Marian Daum (Coatesville), Jennifer Howard (San Diego) • Systems and Parameters Esther Song (Palo Alto), Anders Westanmo (Minneapolis), Cynthia Mansfield (Detroit) • Technician Training Modules Amy Bieryla (Coatesville), LeeAnn Gadbaw (Fayetteville NC) • Frequently Asked QuestionsNaeem Mian (VISN 3), Janet Graham (Louisville) • Education and Training Shawn Toy (Tucson), Thomas Fagan (Richmond), Silverman, Robert (PBM) • Inventory Management Don Lees (PBM Hines), Georgia Stefanidis (Brooklyn VAMC) • Technician Forum Richard Wilson (Coatesville), Christina Andrade (Cheyenne) • Pharmacist Training Modules Daphen Shum (Perry Point), Phillip Coggins (Richmond) • Prime Vendor Group Kathy Walker (Coatesville), Dionne Roney (Charleston)

10. Pharmacy Software Development Workgroups • These are established when a development project is initiated. Participants are volunteers from VAMC Pharmacies. Included below are some of our workgroups • Inpatient Medications • Pharmacy Legacy Enhancements • Bar Code Medications • Pharmacy Re-engineering (multiple) • Women’s Health Initiative –Teratogenic Drugs • DEA Electronic Prescribing of Controlled Substance 10

11. PBM Clinical Informatics Relationship with other Information Technology Program Offices

12. VHA Internal Realignment (2011)Office of Health Informatics/Office of Informatics and Analytics • VHA Under Secretary for Health (USH) identified alignment of the organization around a vision of excellence and reduction of unwarranted variation as priorities • The “Managing Data Workgroup”, one of 6 workgroups guiding the VHA realignment, identified the need to: • Create synergies in health informatics, with the Veteran and the clinician in mind • Create authoritative, accessible, and coordinated approaches to data management, performance measurement, data analysis, and reporting for clinicians and managers • Improve data quality, information governance, and informatics patient safety • The new Office of Informatics and Analytics (OIA) combined assets that had been dispersed across the organization. • The Office of Health Information (OHI) continued its role in defining and monitoring the health business requirements for VHA’s health delivery system. • The new organizational structure was approved in March, 2011. 12

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14. 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.

15. Pharmacy Reengineering Update

16. The Pharmacy Reengineering (PRE) Project • The Pharmacy Reengineering project seeks to replace all VistA Pharmacy applications with a system that provides interoperable, safe, and efficient pharmacy information technology to support VA’s strategic plans for transformation in the 21st Century. • PRE will replace current pharmacy software through the use of new technology, reengineering, and integration of commercial products. These are required to meet current and future workload, technology, and patient safety requirements for VA and Indian Health Services. The potential benefits offered by this program contain eight primary functions, deployed in a phased approach for planned completion by 2014.

17. Pharmacy Reengineered System

18. Order Check Data Flow

20. Pharmacy Reengineering Project Plan FY 11/12/13 • Increment 1 – PRE Foundational Enhancement – Complete • Increment 2 – Pharmacy Enterprise Customization System (PECS) – National Only • Increment 3 – Medication Order Check Healthcare Application (MOCHA v1.0 - Non-Dosing) • Increment 4 – Medication Order Check Healthcare Application (MOCHA v2.0 - Dosing) • Increment 5 – Pharmacy Enterprise Customization System Enhancements - National • Increment 6 – Enhanced Order Checks – Issue Resolution • Increment 7 – Data Migration of the NDF Management System • Increment 8 – Pharmacy Product System National

21. What is MOCHA? Medication Order Check Healthcare Application • MOCHA is the first increment of Pharmacy Reengineering to be released to VAMCs and will provide enhanced non-dosing MOCHA 1 and dosing MOCHA 2 order checks utilizing data from the commercial database First DataBank, and customization using PECS, the VA Pharmacy Enterprise Customization System.

22. MOCHA 2 Drug Dosing Order Checks • MOCHA v2.0 Incremental Delivery • Increment A - Maximum Single Dose Check Warning • Increment B - Daily Dose Range Check Warning • Increment C - Daily Dose Range Check Complex • Increment D - TBD

23. What Does PRE Bring to VA Medical Centers • Maintenance, Support, and Standardization • Moving from local software systems to enterprise software systems benefits VAMCs by providing improved maintenance, support, and standardization of pharmacy informatics software. • Maintenance and updating is provided by First Databank, PBM, and VA IT. • Customization: • PRE uses a COTS product for its clinical decision support data, and the Pharmacy Enterprise Customization System (PECS) allows VA to modify order check codes (significant, and critical) and will allow for non-COTS data under PRE.

24. 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%.

25. 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.

26. NDF Update • Clinical Effect of Drug: Set product specific time limits on order checks against expired or recently discontinued medication orders • Exclude products from order checks when there is no match to FDB. • Auto-Create Default Possible Dosages • Stops the auto-creation of a possible dosage. • More specific, the ability to modify default for an individual product

27. PECS Enhancements • Version 2.0- Fixes database issues but will not be released (May 2011) • Version 2.1- • Upgrades GUI interface • Creation of easy order check GUI • December 2011 (TBD)

28. Pharmacy Product System National (PPSN) • New name for PEPS National • PPS-National will partially replace NDF Management (NDFMS) system • PPS-Local will not be addressed in this upgrade • Data elements from local will be maintained in the system, but will not be used. • PPSN will update NDFMS. Patch will be released to sites as before. • PPSN will incorporate FDB data and FSS data. • User Acceptance testing December of 2011 • Release October 2012 (TBD)

29. How Do We Get Things Done – The Current Information Technology Approach It starts with your question, your concern, your problem, or your idea.

30. 2011 Software Enhancements • Did you know that Pharmacy Benefits Management Clinical Informatics Program Office and the associated Medical Center Pharmacy Informatics specialists worked with the Office of Information and Technology to deliver 86 VistA Patches, and 36 National Drug File Update Patches? Many of these were a result of New Service Requests or problems reported by VA medical center staff through Remedy.

31. Pharmacy Legacy Enhancements (PLE) • Pharmacy Legacy Enhancements – the program in charge of software development to modify VistA software. • PLE is subject to the same PMAS rules as other projects, so everything is delivered in ‘Increments’. 32

32. Pharmacy Legacy Enhancements • Non-Verified/Pending Orders • Categorize STAT and ASAP orders to bring them to the top of the list. • OPAI Functionality Enhancement • Allow sites with multiple vendors Automated Dispensing Devices to set up rules by which VistA will know what product is in which machine, and route the prescription to that machine. • Med Routes Selection Enhancement Functionality to resolve a patient safety risk of an order being placed with a med route that is appropriate for the dosage form (such as INJ, SOLN) but not for the specific medication route (as in a medication that should never be given via the EPIDURAL route). 33

33. FDA Med Guide • Increment #1 Provided updates to the National Drug File Management System which allow data entry of the URL for each available Medication Guide. Delivered as planned. National Release 5/6/10. • Increment #2 Provide Enhancements to NDF to provide the ability to display Medication Guide On-Demand. Provide enhancements to Outpatient Pharmacy to display Medication Guide On-Demand. Created a Centralized repository within CMOP to store the FDA Medication Guides. Loaded the FDA Medication Guides to the CMOP central repository to support the display on-demand features within NDF and Outpatient Pharmacy. National Release 4/20/11 • Increment #3 Enhancements will support Automatic Printing of the FDA Medication Guides when a prescription is being filled. This increment had hardware requirements, therefore the project team requested the technical analysis review (TAR) to assist in addressing proper hardware requirements to ensure performance requirements were met with minimal impact to network traffic. National Release TBD

34. Electronic Prescriptions for Controlled Substances - DEA EPCS The project by which we will electronically prescribe C-II through C-V medications through CPRS and meet DEA rules issued 6/1/2010 • Project status • Requirements Elaboration Document (RED) are complete • VA has requested a waiver of the Interim Final Rule • Blog: Rob Silverman is posting project updates and Q&A on a new blog at: http://vaww.infoshare.va.gov/sites/vapharmacyinformatics/BLOG/DEA_EPCS/default.aspx 35

35. Women’s Health Initiative -Teratogenic Drugs • Documenting and displaying pregnancy/lactation status information • Identifying teratogenicity of medications as well as lactation medications that are harmful to breast fed infants • Provide additional information for medications during the order entry process • Provide order checks, reminders, and alerts • Provide order check information to Pharmacy/Radiology packages to include pregnancy/lactation status information • Provide reporting functionality for all prescribed teratogenic/lactation orderable items 36

36. Software Testing: Pharmacy and Information Technology Partnership (Sample)

38. Pharmacy Informatics Education and Training Initiatives • Significant turnover in pharmacy informaticist positions • Current and future releases of major program enhancements, e.g., MOCHA • Health Informatics Initiative (hi2) addressing the collective competency of the informatics workforce

39. Pharmacy Informatics Education and Training Initiatives • Current training modalities • Real-time LiveMeetings • Recorded content on SharePoint sites • PowerPoint presentations • Annual conferences (Hi, everybody!) • Frequently Asked Questions / Knowledge Experts • Proposed additional opportunities • Interactive webinars • Face-to-face training independent of conferences • Stay tuned for the workgroup report…

40. iEHR Pharmacy Scope • Provide the ability for a joint DoD/VA pharmacy system to enable pharmaceutical services (e.g., process medication orders and prescriptions) without any degradation to existing functionality. • Align joint business processes and requirements for: • Inpatient Pharmacy (order fulfillment only) • Outpatient Pharmacy (order fulfillment only) • Inventory Management • All orders received by the joint DoD/VA pharmacy system will be available enterprise wide for medication therapy management. 41

41. iEHR Pharmacy Request for Information • RFI posted on November 30, 2011 • RFI responses due on January 2, 2011 • Received nine responses

42. iEHR Next Steps • Review RFI Responses • Request for Proposal

43. Questions