0. Tom Fagan Pharmacy Benefits Management Clinical Informatics Instructor
Product Effectiveness  Benefits Realization Assessment of the Pharmacy Re-Engineering (PRE) Medication Order Check Healthcare Application (MOCHA) software
Welcome a little about me supplement bio
Learn about you poll audience for inpatient , outpatient, CPRS users
Hawthorne Effect general unintentional effect of positive change on system caused by observing or measuring usually occurs with human behavior
Tom Fagan
Pharmacy Benefits Management Clinical Informatics Instructor

1. Learning Objectives
Understand the Mission of Pharmacy Benefits Management
Understand the Background on Pharmacy Re-Engineering Project (PRE) including (MOCHA) Medication Order Check Healthcare Application
Understand the reason and goals for Benefits Realization assessment of PRE including MOCHA by OHI PE Team
Understand the data sources, methodology and rationale used in assessment
Understand initial assessment findings and recommendations
Unless NOTED Presentation details are based upon 90 page report titled:
VETERANS HEALTH ADMINISTRATION
OFFICE OF HEALTH INFORMATION
PRODUCT EFFECTIVENESS
PHARMACY BENEFITS MANAGEMENT
PHARMACY RE-ENGINEERING
INITIAL BENEFIT REALIZATION MEASUREMENT REPORT

2. Mission of Pharmacy Benefits Management
To improve the health status of veterans by encouraging the appropriate use of medications in a comprehensive medical care setting.
Functions
Drug Benefit Design
Evidence-Based Formulary Management
Utilization Management
Staff Education
Patient Safety
Drug Benefit Design – Managing and design of drug coverage and benefits for Veterans
Evidence-Based Formulary Management – Managing of the VHA National Formulary, the VA list of approved drugs and supplies for VA pharmacies
Utilization Management - Evaluating and determining the coverage and the appropriateness of medical care services across the patient healthcare continuum to ensure the proper use of resources
Staff Education – Managing programs and initiatives to promote staff education and awareness
Patient safety – Promoting patient safety through research, education, system and process improvements, and safety initiatives, including VAMedSafe, the PBM Center for Medication Safety, and adverse drug event (ADE) reporting
Mission Source
VA Pharmacy Benefit Management Services, November 2011,

3. Clinical Informatics
Application of Information Technology to deliver Healthcare Services
Clinical Informatics is the application of software tools from
informatics and information technology to deliver healthcare services.
pharmacy education and training role develop knowledgeable workforce
Next VistA software PRE
Discipline at the intersection of information science, computer science and health care

4. (PRE) Pharmacy Re-engineering Background
Began in 2002
Multiple Increments Project Management
Main Goal to Improve VistA Pharmacy Package
Respond to Patient Safety Issues
Medication cost reduction
Improved workflow and process
PRE goal is to update and improve the VistA Pharmacy Package to provide the ability to respond to ever-changing patient safety issues by reducing drug interactions and adverse drug events, decreasing medication costs, and providing clinicians with an improved workflow and processes.  

5. PRE Increments First Iteration
Increment 1 – PRE Foundational Enhancement
Increment 2 – Pharmacy Enterprise Customization System (PECS)
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
Increment 6 – Enhanced Order Checks
in accordance with Office of Information and Technology’s (OIT) Program Management Accountability System (PMAS)

6. PRE Pharmacy Re-engineering Components
MOCHA
Medication Order Check Healthcare Application
PECS
Pharmacy Enterprise Customization System
PPS
Pharmacy Product System
More details to come on PECS and MOCHA
Source Rob PRE update slides Mar 2012

7. https://vapreapp1.aac.va.gov:8443/ct/public/
Accessing PECS
Have your ADPAC assign you the following security key: 
PSS_CUSTOM_TABLES_REQUESTOR
Access PECS through this link:     
Welcome.action
Any clinician with VistA access can request access to PECS.
Encourage all Pharmacy ADPACs to request this access and become familiar with PECS.
PECS customization request for drug-drug order checks
The Easy Search tab added in PECS v 2.1.

8. Medication Order Check Healthcare Application
MOCHA V1.0
Medication Order Check Healthcare Application
MOCHA v1.0
Rolled out during the summer of 2011
Delivers a valuable enhancement to medication order checks in the Pharmacy and CPRS packages
Utilization of a clinical drug database vendor, First Databank (fdb)
Enhanced Therapeutic Classification (ETC) allows for multiple classes per drug, thereby reducing the number of clinically inexact or inappropriate warnings
Source Rob PRE update slides Mar 2012

9. MOCHA V2.0 MOCHA v2.0 (Dosing) Development
Introduces dosage order check functionality which will reduce medication errors, adverse events, and potential deaths
Provides an extremely valuable tool to VA clinicians in CPRS, Inpatient Pharmacy, and Outpatient Pharmacy
Version 2.0 consists of a maximum single dose check derived from the patient’s age, weight, and body surface area (BSA)
Currently installed in six test site environments with a planned national release of July 2012
Source Rob PRE update slides Mar 2012

10. Stated Benefits of PRE Increased Patient Safety
Increased Efficiency of Prescription and Order Processing
Decreased Costs
Increased Satisfaction
Increased Regulatory Compliance
More details in measureable goals

11. Goal for Assessment
Office of Health Information (OHI) Product Effectiveness (PE) Benefits Realization (BR) Assessment
One key question
Is VHA realizing the intended benefits from the PRE functionality, and if not, what can be done to make needed improvements?
PBM requested assessment Independent assessment
Detailed goals to follow

12. Measureable Goals Patient Safety
Increased Efficiency of Order Processing
Decreased Costs
Increased Satisfaction
Increased Regulatory Compliance
Measurement and analysis
Examples
#1 Decrease in vaADERS, Remedy flagged as potential patient safety
#2 Increase 30 day equivalents outpatient RX, decrease unique outpatient RX per patient
#3 Decrease facility pharmacy inventory , cost of pharmacy VistA patches
#4 Increase Pharmacist and Pharmacy Technician, Patient surveys
#5 TBD number of Pharmacy based Joint Commission Inspection Deficiencies

13. Data Sources PBM Database ProClarity Cube HR Employee Cube
Non-Formulary Request Processing Reports
National Drug File support Group
PBM Inventory Data
PBM Order Check Analysis Worksheet
vaADERS
Office of Information IT Patient Safety Office Database:
#1 PBM Database: The PBM Database captures prescription level data for all prescriptions processed in the VA pharmacy system and contains data going back to Fiscal Year (FY) The database utilizes source data from the Outpatient Pharmacy package, the Inpatient Medications package, the Controlled Substance package, and the Laboratory package. The PBM Database provides the ability to review drug utilization trends, analyze prescribing habits, assess disease management guidelines, and also has a variety of other uses.21 The PBM Database is not available publically, so data extraction requests will be made directly to PBM.
#2 HR Employee Cube: The HR Employee Cube captures monthly snapshots of VA employee information, including age, gender, occupation, etc. Specifically, it includes the number of employees working as pharmacists and pharmacist technicians at each VA facility. The cube is managed by the VHA Support Service Center (VSSC) and is located on the VA intranet at the following link:
#3 Non-Formulary Request Process Reports: The Non-Formulary Request Process Reports track the number of non-formulary requests received, approved, denied, and the average request processing time for each VA facility. This data is captured quarterly, beginning in the third quarter of The reports are located on the VA intranet at the following link:
#4 National Drug File Support Group: The National Drug File Support Group updates and maintains the drug-drug interaction file in VistA. The team meets monthly via telephone and in person annually to discuss drug interaction updates for the NDF. The group tracks and maintains various NDF data elements for PBM, including the number of interaction reviews and the processing time for each. The data is not available publically and will be requested directly from PBM.22
#5 PBM Inventory Data: PBM maintains inventory related data for all VA facilities, including an annual inventory cost assessment and the number of turns on inventory. This data is not available publically and will be requested directly from PBM.
#6 PBM Order Check Analysis Worksheet: PBM is tracking order check data for six VA facilities in an MS Excel spreadsheet. This data includes a breakdown of Order Checks pre- and post-MOCHA, as well as a summary of the types of Order Checks. This data is not available publically and will be requested directly from PBM.
#7 VA Adverse Drug Event Reporting System (vaADERS): The VA Adverse Drug Event Reporting System is a web portal that enables VA facilities to report ADEs in one consolidated system. This database tracks the number of ADEs at each VA facility across the VHA. Although it requires special access, the portal/data is located on the VA intranet at the following link: The PE Benefits Realization does not have access to the portal, so data will be requested directly from PBM.
#8 Office of Information IT Patient Safety Office Database:
The Office of Information IT Patient Safety Office tracks information technology issues that may pose a safety risk to patients. When a helpdesk ticket is submitted in the VA, the submitter has the option to classify the issue as a patient safety issue. If this is done, the IT Patient Safety Office utilizes its information technology and clinical experience to evaluate and score the safety issue. This helps the VA determine and prioritize what issues to fix. The office maintains data on all potential patient safety issues and is able to provide data specifically related to the pharmacy packages. Requests for data are made through their VA intranet site, located at the following link:
Survey next

14. Surveys VHA National Survey of Pharmacists
PE Customer Satisfaction Focus Groups
VA All Employees Survey
Survey of Healthcare Experiences of Patients
#1 VHA National Survey of Pharmacists: This questionnaire will be administered by the PE group to gauge pharmacist staff satisfaction associated with the pharmacy systems, potentially in May However, this survey is in the early development stages, so little information is available at this point.
#2 PE Customer Satisfaction Focus Groups: The PE Customer Satisfaction Team will also design and execute focus groups to capture provider satisfaction associated with the pharmacy systems, potentially in the spring of However, this is in the early development stages, so very little information is available at this point
#3 VA All Employees Survey: The purpose of the AES is to collect information on VA employee’s perceptions of their work place and their satisfaction with the Department of Veterans Affairs. The survey is comprised of three main components: the Job Satisfaction Index (JSI) which is used to assess the employee’s individual satisfaction with key job features; the Organizational Assessment Inventory (OAI) which measures the employees’ perceptions of conditions in their immediate work group; and Culture which identifies employee perceptions of the general atmosphere at their facility overall. The cube is managed by the VSSC and is located on the VA intranet at the following link:
#4 Survey of Healthcare Experiences of Patients: The SHEP survey collects data on various aspects of the patient experience, both inpatient and outpatient, including communication with hospital staff and overall rating of the hospital amongst other things. The cube is managed by the VSSC and is located on the VA intranet at the following link:

15. Methodology Overview of BR
Product Effectiveness Mission – Independent Assessment and Analysis
Benefit Realization - evaluate benefits against a specific outcome
Initial Measurement (now)
Post Implementation Performance (future)
Method used are tied to goals and mission
PE’s mission is to perform independent assessments and analysis on health and business to ensure process improvements are effective and meet the needs of the customer in terms of function
BR to help achieve maximum value from product investments through the independent identification, measurement and evaluation of a specific product or service’s benefits against the expected outcomes
Compare and analyze the results for trending going forward benefits of PRE enhancements were actually achieved.

16. Methodology Scope PRE Multiple Increments Initial Post Implementation
Increments in accordance with project PMAS change based upon shifting priorities and resources
Some metrics will only be impacted by specific Metrics, add metrics as dictated by the future PRE enhancements

17. Rationale Measurements Findings Recommendations
All are linked to one of the following MAIN goals
Respond to Patient Safety Issues
Medication cost reduction
Improved workflow and process
Staff Satisfaction
Increased Regulatory Compliance

18. Initial Assessment Findings
Establish a Baseline before PRE upgrades
Benchmark for future comparison
PMAS Incremental
PRE data was gathered for a total of twelve months, from January 2010 to December 2010; however, dates and timeframes may vary based on data availability for each metric, constraints of individual measures, and/or the resources needed to obtain the information.

19. Initial Assessment Recommendations
Patient Safety
Alert Fatigue
Staff Satisfaction
Ongoing monitoring in key areas
Ongoing challenge to balance staff satisfaction with patient safety with alert fatigue in the middle patient safety will usually win out

20. Major Recommendation Measurements on Annual Basis
Identify Trends due to upgrades
The following major tasks will be undertaken to compare post- implementation data to the initial measurement results:
1. Review the List of Benefits, Performance Measures, and Metrics to determine if items should be added or removed.
2. Review the Measurement Plan to determine if metric data can be captured using a different, more efficient and/or accurate method than initially planned.
3. Capture post-implementation data
4. Analyze post-implementation data, and identify and analyze any variance between the initial and post-implementation data
5. Report findings, lessons learned, and action plan recommendations PBM leadership.

21. Recommendation Monitoring Details
Safety Metrics
MOCHA
Staff Satisfaction
Work Flow
#1 continue to monitor ADE
#2 Order Check Analysis including enhanced drug-drug interactions
#3 Staff recommendations and survey
#4 Staff recommendations change visual display and implement other improvements
Missing #5 Regulatory TBD

22. Key Findings Increased Patient Safety and Decreased Costs
Increased Satisfaction Mixed
-MOCHA
#1 Adverse Drug Events are expensive assuming preventable ADE cost $4,000 reducing 250 per year would save $1 Million
#2 MOCHA reactions from Pharmacist and Provider are mixed satisfaction increase with use
Although MOCHA v1.0 did not increase the overall Medication Order Checks as a percentage of new orders, as compared to the Post-CPRS v28 baseline, it did create a new alert when the system is unable to perform an Order Check. Much of the negative perception regarding MOCHA v1.0 may be due to this specific unable to perform Order Check alert, in addition to the increase in the number of alerts due to CPRv28 discussed earlier. PBM has already deployed a patch to address one of the primary causes of the unable to perform Order Check alert, which should reduce the number of alerts in future measurements.

23. ASHP 2009 Drug Drug Interaction (DDI) Survey
Pharmacists
Identify Areas for Improvement
Knowledge Gap –no formal education on how to evaluate and respond to order checks
American Society of Health‐System Pharmacists
Survey of 1,745 in 2009 presented as NOLA ASHP mid year meeting in 2011.
Alert fatigue
Accuracy
Inability to customize, who, what and when
80% do NOT provide formal education to pharmacist or clinicians on how to evaluate and respond to DDI alerts

24. Summary Benchmark Established Increment Assessment
Is VHA realizing the intended benefits from PRE if not what can be done to make needed improvements?
Main goal determine whether the complete list of anticipated benefits is being realized
Patient Safety
Increased Efficiency of Order Processing
Decreased Costs
Increased Satisfaction
Increased Regulatory Compliance
also to understand the impact of PBM corrective actions,
continued performance measurements should be conducted and compared back to the benchmarks established in this report