1. Promoting high quality, cost effective drug therapy throughout the Military Health System The Basics for a Successful MTF P&T Meeting Prepared by the DoD Pharmacoeconomic Center

2. DoD Pharmacoeconomic Center www.pec.ha.osd.mil Introduction LCDR Joseph B. Lawrence –PEC Navy Pharmacist Consultant Purpose of discussion –Basic tools and strategies for P&T –Mock agenda for a MTF P&T

3. DoD Pharmacoeconomic Center www.pec.ha.osd.mil Topics of Discussion Purpose of P&T Organization and operation Functions and scope Assembling a quality meeting agenda Information resources for MTF specific data and research Medication use evaluation Drug class review. Reports JCAHO and other surveys

4. DoD Pharmacoeconomic Center www.pec.ha.osd.mil Purposes Policy development –Evaluation, selection and therapeutic use of drugs and related devices Education –Programs for drug related matter for medical team Goal –ensure medications are used safely and appropriately

5. DoD Pharmacoeconomic Center www.pec.ha.osd.mil Organization and Operation Composition: physicians, pharmacists, nurses, administrators, QA coordinators, others Physician chairperson Pharmacist recorder Meet regularly Invite ad hoc members and specialist as needed Sufficient time to review meeting materials Recommendation presented to medical staff Liaison with other organization committees concerned with drug use Actions routinely communicated Conflict of interest policy Attentive to ASHP, AHA, JCAHO, DOD, ect…

6. DoD Pharmacoeconomic Center www.pec.ha.osd.mil P&T Committee Organization –Chairperson Respected member of medical staff Familiar with and advocate for progressive pharmacy Effective ally for pharmacy with medical staff and hospital administration –Secretary Director of Pharmacy Sets agenda with chairperson

7. DoD Pharmacoeconomic Center www.pec.ha.osd.mil Functions and Scope Evaluative, education and advisory capacity to the med staff Develop a formulary of drugs for the organization Programs/procedures to help ensure the safe and effective drug therapy Programs/procedures to ensure cost-effective drug therapy Educational programs for medical team Participate in QA activities regarding medication Monitor/evaluate ADR DUE Advise pharmacy in effective drug distribution and control Disseminate information of actions to health-care staff

8. DoD Pharmacoeconomic Center www.pec.ha.osd.mil P&T Agenda Delivered via member preference (email, hard copy, etc) Delivered with adequate time to review before meeting (1 week) Informative enclosures –Eg: drug monographs, adverse drug reaction reports, and policy changes Date/time/location of the meeting Review of old business –Medical staff notification –Minute routing comments –Pharmacy budget –Standing issues New business –Requests for change in formulary –Drug/product complaint –Drug recalls –Narcotic overlap –ADR –Planning for next meeting

9. DoD Pharmacoeconomic Center www.pec.ha.osd.mil P&T Committee Organization –Follow-up Actions should be conveyed to all health-care professionals Recommendations are to be passed on to the appropriate committee

10. DoD Pharmacoeconomic Center www.pec.ha.osd.mil Formulary Management Formulary –Definition: a continually revised compilation of pharmaceuticals that reflects the clinical judgment of the medical staff

11. DoD Pharmacoeconomic Center www.pec.ha.osd.mil Formulary Management Formulary system management –Definition: method where the medical staff working through the P&T committee, evaluates, appraises, and selects from the numerous available drug products those considered most useful in patient care

12. DoD Pharmacoeconomic Center www.pec.ha.osd.mil Formulary Management Formulary system management –Theory: a well designed formulary can guide physicians to prescribe the safest and most effective agents for treatment of a particular condition.

13. DoD Pharmacoeconomic Center www.pec.ha.osd.mil Formulary Management Objectives –Decrease drug cost –Assure high quality care –Provide information on drug products –Provide information on organizational policies/procedures –Development of institution specific guidelines/protocols

14. DoD Pharmacoeconomic Center www.pec.ha.osd.mil Formulary Management Purpose for ongoing management –Removal/addition of drugs from/to the market –Changes in hospital policies/procedures –New clinical information available Clinical trials Guidelines Safety

15. DoD Pharmacoeconomic Center www.pec.ha.osd.mil Formulary Management Advantages –Ensure quality and appropriateness of drug use –Educational for staff regarding most effective agents –Economic benefits Disadvantages –Only reduces cost –Compromises patient care –Limits physician prescribing authority

16. DoD Pharmacoeconomic Center www.pec.ha.osd.mil Formulary Management Principles –Drug product selection Comparison of all aspects of an agent to that of similar medications. Should be based on scientific evidence Consider effectiveness, safety and cost

17. DoD Pharmacoeconomic Center www.pec.ha.osd.mil Formulary Management Principles –Formulary Maintenance Addition/deletion –Newly approved agents –New information available (i.e. safety, efficacy) –Tracking use of nonformulary agents Single drug review –Compare single drug to other drugs that are similar –Focus is on a single drug Therapeutic class review –Compares/contrasts all the agents in a single class –Focus is not on a single drug

18. DoD Pharmacoeconomic Center www.pec.ha.osd.mil Drug Product Selection Development of a drug monograph –Purpose: to evaluate various medications to ensure that patients receive drugs that are safe,therapeutically effective and cost effective

19. DoD Pharmacoeconomic Center www.pec.ha.osd.mil Drug Product Selection Development of a drug monograph –Preparation Identify drug to evaluate Determine if there are similar agents on formulary Obtain background information –Clinical and safety information –Indications –Cost –Clinical trials

20. DoD Pharmacoeconomic Center www.pec.ha.osd.mil Drug Product Selection Development of a drug monograph –Components Summary page Introduction Pharmacology Pharmacokinetics Clinical efficacy

21. DoD Pharmacoeconomic Center www.pec.ha.osd.mil Drug Product Selection Development of a drug monograph –Components (cont) Adverse effects Drug Interactions Cost and dosage Conclusion/Recommendations References

22. DoD Pharmacoeconomic Center www.pec.ha.osd.mil Drug Product Selection Points to consider – addition to formulary –Clinical effectiveness, safety, and cost –Comparison to similar agents –Comparison to standard therapies –Advantages/disadvantages –Niche

23. DoD Pharmacoeconomic Center www.pec.ha.osd.mil Drug Product Selection Therapeutic Interchange –Definition: interchange of various TE drug products by pharmacists under pre-defined arrangements with the prescriber

24. DoD Pharmacoeconomic Center www.pec.ha.osd.mil Drug Product Selection Therapeutic interchange –Elements for successful implementation P&T approval Scientific/clinical evidence Medical staff education Mechanism to implement interchange Maintenance

25. DoD Pharmacoeconomic Center www.pec.ha.osd.mil Drug Product Selection –Therapeutic interchange process Substitute generic for brand Give individual agents in place of combination product Switch from intravenous to oral antibiotics Change to different agent in same class Interchange may be automatic or may require notification

26. DoD Pharmacoeconomic Center www.pec.ha.osd.mil Therapeutic Interchange Advantages –Reduced inventory –MTF saves money –Encourages compliance with formulary Disadvantages –Confusing to patients –Patients may think that drugs are NOT equally effective –Preferred product may change based on contracts

27. DoD Pharmacoeconomic Center www.pec.ha.osd.mil Information resources Local data CHCS CIS Pharmacy automation system (ScriptPro, Pyxis, ect) Prime Vendor PDTS DoD level data PDTS M2

28. DoD Pharmacoeconomic Center www.pec.ha.osd.mil Utilizing CHCS data Obtaining CHCS data Capturing CHCS data in Kea™ Importing columnar reports into Excel™ Importing delimited reports into Excel™ Sorting data in Excel™ Using Access queries to clean up data Miscellaneous tactics to clean up data before exportation including Word™ and Monarch™

29. DoD Pharmacoeconomic Center www.pec.ha.osd.mil 29 Obtaining CHCS data Do it yourself –Canned reports (dur, cost)cost –Ad hoc report Request from CHCS administration –Delimited with “^” –Specify columns

30. DoD Pharmacoeconomic Center www.pec.ha.osd.mil 30 Capturing CHCS data in Kea™ Print report to “spool” –Command policy (i.e., after 2200) –Big report take longer Print spooled report (PSR) –don’t print yet! Set Kea to “capture incoming data”capture incoming data Select file location and namefile location and name Set Kea to “end capture”end capture

31. DoD Pharmacoeconomic Center www.pec.ha.osd.mil 31 Importing text reports into Excel™ Open Excel File, Open, (change file type to.txt) Import text wizard –ColumnsColumns –DelimitedDelimited

32. DoD Pharmacoeconomic Center www.pec.ha.osd.mil Sorting data in Excel™

33. DoD Pharmacoeconomic Center www.pec.ha.osd.mil Cost Report VERIFY CODE: Checking multiple sign-ons... Good evening JOE, you last signed on today at 19:54 IVM IV Menu NSM Narcotic System Menu OPM Outpatient Menu UDM Unit Dose Menu PSM Pharmacy Support Menu PRM Pharmacy Reports Menu SFM Supervisory Functions Menu Select Pharmacy System Menu Option: KP KP Pharmacy Cost Reports Return

34. DoD Pharmacoeconomic Center www.pec.ha.osd.mil Capture incoming data Back

35. DoD Pharmacoeconomic Center www.pec.ha.osd.mil File location Back

36. DoD Pharmacoeconomic Center www.pec.ha.osd.mil End capture jpg Back

37. DoD Pharmacoeconomic Center www.pec.ha.osd.mil Excel open txt Back

38. DoD Pharmacoeconomic Center www.pec.ha.osd.mil Text import wizard – step 1 Step 2

39. DoD Pharmacoeconomic Center www.pec.ha.osd.mil Text import wizard – step 2 Step 3

40. DoD Pharmacoeconomic Center www.pec.ha.osd.mil Text import wizard – step 3 Back

41. DoD Pharmacoeconomic Center www.pec.ha.osd.mil Delimited file step 1 Step 2

42. DoD Pharmacoeconomic Center www.pec.ha.osd.mil Delimited file step 2 Back

43. DoD Pharmacoeconomic Center www.pec.ha.osd.mil Obtaining DoD level data PDTS –PDTS request: http://www.pec.ha.osd.milhttp://www.pec.ha.osd.mil –PDTS training M2 –Command authorized user

44. DoD Pharmacoeconomic Center www.pec.ha.osd.mil Outline the steps in developing this process improvement using the FOCUS-PDCA model

45. DoD Pharmacoeconomic Center www.pec.ha.osd.mil Example P&T Process improvement Wanted to improve error reporting, including the reporting of near miss errors. MTF filled an average of 33,000 prescriptions per month between Oct 02 and Jul 03 During this time period an average 4.1 errors/month were documented. No near miss errors were documented

46. DoD Pharmacoeconomic Center www.pec.ha.osd.mil Definition of a Medication Error "A Medication Error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communications; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use."* Source: The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP), 1995.

47. DoD Pharmacoeconomic Center www.pec.ha.osd.mil Types of error No Error A Circumstances or events that have the capacity to cause error. Error, No Harm B An error occurred but the error did not reach the patient (An "error of omission" does reach the patient). C An error occurred that reached the patient but did not cause patient harm. D An error occurred that reached the patient and required monitoring to confirm that it resulted in no harm to the patient and/or required intervention to preclude harm. Error, Harm E An error occurred that may have contributed to or resulted in temporary harm to the patient and required intervention. F An error occurred that may have contributed to or resulted in temporary harm to the patient and required initial or prolonged hospitalization. G An error occurred that may have contributed to or resulted in permanent patient harm. H An error occurred that required intervention necessary to sustain life. Error, Death I An error occurred that may have contributed to or resulted in the patient's death. Near Miss Miss

48. DoD Pharmacoeconomic Center www.pec.ha.osd.mil P&T Process Studied current process Identified areas of needless complexity or redundancy Looked at outcomes and the best way the process should work Considered factors such as cost restraints, expandability and maintainability

49. DoD Pharmacoeconomic Center www.pec.ha.osd.mil P&T Discoveries Current process for reporting errors was too time consuming –All reports were documented on a written report –Routed through chain of command Felt many people didn’t document errors due to fear of repercussions from chain of command and/or didn’t want to bother with the hassle of filling out a “report”

50. DoD Pharmacoeconomic Center www.pec.ha.osd.mil P&T Collaboration Team assembled from pharmacy personal, Risk Management, Performance Improvement and PIPA. Goal was to improve process for reporting errors by eliminating fear of reporting and making it easier to report errors.

51. DoD Pharmacoeconomic Center www.pec.ha.osd.mil Plan the Process Improvement New process was instituted for reporting errors. Points of contacts identified at all pharmacies to facilite the reporting of errors into MedMarx New forms created Staff trained

52. DoD Pharmacoeconomic Center www.pec.ha.osd.mil Do the Improvement, Collect Data, Analyze Med errors measured pre and post Pharmacy staff entered errors into MedMarx Problems encountered: –Required continuous awareness training –Staff deployment and turnover

53. DoD Pharmacoeconomic Center www.pec.ha.osd.mil Start of FOCUS PDCA New Process Implemented

54. DoD Pharmacoeconomic Center www.pec.ha.osd.mil

55. DoD Pharmacoeconomic Center www.pec.ha.osd.mil MTF