1. Pharmacy Benefits Management Clinical Informatics and Pharmacy Re-engineering Strategic Initiatives Lynn C. Sanders, Pharm D. Associate Chief Consultant PBM Clinical Informatics/Pharmacy Re-engineering
Good Afternoon. Today’s presentation will be an overview of the initiatives, projects, and activities the PBM Clinical Informatics and Pharmacy Re-engineering office is currently engaged.

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
For those of you that don’t know about our program office we’ve been in existence since 2001, in response to a study that indicated the VA Pharmacy Information System was a major weakness for VA, and had several patient safety concerns.
Dr. Jeff Ramirez started the program, he retired last year and I have his position. He didn’t have really big feet so I think I can fill his shoes but will add a two and half inch heal to them.
Our team is made up of our admin Kim Moffitt,
LuAnne Barron is the lead manager for Pharmacy Re-engineering assisted by Amy Colon, Mike Martinko, and Oliver Havens.
Rob Silverman is the lead manager for Clinical Informatics, innovations, education and training
Don Lees you all know for National Drug File, and Inventory, but he is also the lead for the Pharmacy Enterprise Product System that will replace NDF, and support customization of VA medication order checks
Don is assisted by Deborah Coulter and Todd Schippers 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
Our program offices top priorities are:
The Re-engineering and Enhancement of the VA Pharmacy Information System to improve patient safety, efficiency, and care to Veterans
We work to Provide communications and support to VAMC pharmacies with informatics and analytics information, problem resolution, and education and training.
Under the direction of Mike Valentino we Represent PBM as the business owner in relationships within VA including VA IT and VHA Health Information Offices) as well as nationally outside VA. 3 3

4. PBM Clinical Informatics Relationship with the Field
In representing PBM with these other organizations we strive to foster the evolution of pharmacy informatics and be in touch and responsive to the needs of VA Medical centers.

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.
We support and adopt the ASHP definition of Pharmacy Informaticist applies to pharmacist, technicians and other specialists and says:
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.
In order to support this we initiated and are close to having our directive approved which will require each medical center standardize pharmacy informaticist access to VA IT systems providing minimum requirements of
Specified VistA Menus and VistA Security Keys
FileMan files required by the pharmacy informaticist and VistA access required of any service APDAC but not specific to pharmacy and
Any Vista Security Keys that are required to access Vista options required in the details of this directive.
We believe that this will greatly improve efficiency in accessing pharmacy information. 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
We also have begun to outline some of the responsibilities and capabilities that a VA pharmacy informaticist should have including:
Implementation, monitoring and reporting of and for VistA and VistA interfaced systems
Maintenance and support of automated dispensing and storage systems, partnering with BioMed departments.
Act as subject matter and knowledge experts for pharmacy information systems
Testing of VistA software for pharmacy
Communicating with local IT staff and communicating with PBM clinical informatics program office.
Reporting system defects such as remedy and IT patient safety issues and concerns
When they have a great idea submitting it to the VHA IT.

8. Our approach to Fulfilling Excellence in providing the Best Patient Facing Care environment is to continue to use informatics to evolve the relationship between pharmacy management, practice operations, clinicians, and informaticists

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 Questions Naeem 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)
The PBM Pharmacy Informatics Advisory Task Force provides our office with standing groups of knowledge experts from the field.
We rely on these folks to provide information, assist with problem solving, analysis, and development efforts.
These include:
Automation Technology
Systems and Parameters
Technician Training
Frequently Asked Questions
Education and Training
Inventory Management
Technician Forum
Pharmacist Training Modules
And the Prime Vendor system analysis group
Some major output of this task force are Automation Fridays, the OIG Reporting Tool, and
Support for our Share Point They also work to organize our National Pharmacy Informatics Meetings, and we’ll be having our 4th face to face meeting in May.
We also continue to modify initiatives this group works on to meet the needs of VA Pharmacy.

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
The other major support we get from VA medical center staff are our Software Development Workgroups.
If any folks are in the audience that have participated on the Advisory Task Force or Workgroups in the audience will please stand.
If you’re on or have been on one of our software development workgroups or the advisory task force, please press one on your clicker.
If you’d like to be press 2.
If everyone can clap your hands for them a hand because they are innovators and problem solvers and should be applauded for their fantastic efforts. 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 12

13. 13

14. 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” 
Distribution Date: August 16, 2011
Notice Number PBM  
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.
The PBM works with OIT, OHI, and the National Center for Patient Safety to notify VA medical centers of patient safety related problems with VistA software. 14

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
This slide depicts the new architecture design for order checks. This slide depicts the basic flow of order check data with the implementation of MOCHA V. 1.0.
When a VistA application, such as Outpatient Pharmacy requests an order check to be performed, an XML message is sent from VistA to First DataBank
The PEPS side of the interface will receive, validate the format, and triage the request before sending it on to the FDB Drug Information Framework which will perform the requested order check(s) and return the results.
The way RDI, or Remote Data Interoperability works has not changed.
For duplicate therapy and drug interaction order checks, the remote information is bundled with local information on the patient as the order check request.
MOCHA V. 1.0 just added another step, instead of the order checks being performed all within VistA, we now have the order check performed by FDB. 18

19. Because we are changing to having data stored and updated at a national/regional data center that is located at the Austin Information and Technology Center we have had to address concerns with communication failures.
We have developed systems to reroute the local VistA transmission to an alternate server in the event the national Austin server experiences downtime. 19

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. MOCHA 2 Schedule iA - Max Single Dose Check Warning
2011
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
iA - Max Single Dose Check Warning
iB - Daily Dose Range Check Warning Simple
iC- Daily Dose Range Check Complex

24. 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.

25. 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%.

26. MOCHA Impact on 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.

27. 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

28. 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

29. 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

30. How Do We Get Things Done – The Current Information Technology Approach
It starts with your question, your concern, your problem, or your idea.
I talked about the WHO and the planned new approach to information technology development, but I think its important to share with you how we get things done, and maybe part of why it takes so long to get things done.

31. 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.

32. 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’.
Pharmacy Legacy Enhancements is one of our major core initiatives. PLE works on defects, remedy tickets, patient safety issues, class 3 conversions, and new service requests.
Its subject to the same PMAS restrictions as other projects. 32

33. 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

34. 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

35. 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:
BLOG/DEA_EPCS/default.aspx 35

36. 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
The Joint Commission (JC) requires patient-specific information to be readily accessible to those involved in the medication management and the monitoring of high-risk or high-alert drugs, including medications that carry a higher risk for adverse outcomes.
Through the enhancements below, clinicians would be provided with an order check when initially prescribing and renewing medication prescriptions for teratogenic drugs to women of child-bearing potential as well as to women who are pregnant and lactating. The Pharmacy package would receive an alert if a potentially teratogenic medication was being prescribed to women who are pregnant or lactating. In addition, the prescribing provider would be notified during an encounter that a patient who is pregnant or lactating has a prescription for a teratogenic drug so that appropriate actions could be taken. Enhancements include: 36

37. Software Testing: Pharmacy and Information Technology Partnership (Sample)
Every product is under goes laboratory testing and field testing.
Our pharmacy informaticists volunteer to test and accept the product. If they identify defects or it doesn’t work like it should, it goes back to developers and can’t be released until those are corrected.
Our volunteer pharmacy testers are amazing and often tell the developers how to fix the problems they have identified.
If you are or have been informatics tester for pharmacy software and patches, please stand up and press 1 on your Clicker.
If you’d like to be a tester press 2.

39. 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

40. 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…

41. 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

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

43. iEHR Next Steps
Review RFI Responses
Request for Proposal

44. Questions