2010 … New Decade, New Tools

1. 2010 … New Decade, New Tools Pharmacy Informatics: Out of the Silo, Into the Field Rob Silverman, Pharm.D. Program Manager, PBM Clinical Informatics Robert.Silverman@va.gov April 28, 2010

2. 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

3. 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

4. Project List, continued • Pharmacy-related • 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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!

11. 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

12. 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

13. 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

14. 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. • Change routines • Change files • Add routines only • Add routines and files • Combinations of the above…

15. 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!

16. 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

17. 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

18. 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

19. 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.

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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.

27. Conclusions • The process is slow, but has been successful • 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) • This presentation likely only scratches the surface of important innovative ideas within VA