1. VHA INNOVATION PROGRAM Innovation #263 Parking A Prescription (PARK) VHA ISB Business Case September 25, 2013

2. VETERANS HEALTH ADMINISTRATION Project Background Problem Statement – The VA pharmacy computer system does not allow for the updating or changing of a prescription without a fill generated. This has created the following problems: Tremendous amount of waste in expensive drugs – Once the prescription is dispensed to Veteran, pharmacies cannot take it back Medication reconciliation is almost impossible with the current system Patient confusion due to receiving multiple bottles of the same medication Veterans being charged copay for medication they did not request Potential for erroneous claims with regard to insurance billing Description of Proposed Solution – Provides a method for providers to be able to “PARK” a prescription placing it in a status of “hold until requested by patient or provider.” The provider would be able to write for the medication order or edit current medication orders and then choose whether the medication should be sent immediately (current functionality) or to wait for the patient to request the medication (parking). Additionally: The pharmacy would be able to prepare the order electronically in the patient record, but not fill the medication until the patient requests it The Veteran can request using the AudioCare telephone refill request system, the MyHealtheVet (MHV) internet refill system, or mail in their request Any member of the medical team can request the medication be sent using CPRS 1

3. VETERANS HEALTH ADMINISTRATION Execution Status Fully developed PARK prototype in the Innovation Sandbox – Includes: the necessary software enhancements/modifications to VistA Pharmacy, CPRS, and AudioCare telephone refill request system – Does not include: MHV components (not available in the Sandbox) Final code and documentation is being submitted to OSEHRA Full support of Pharmacy Benefits Management (PBM) leadership for enterprise-wide release PARK supports fulfillment of the Medication Reconciliation NSR (20100914) submitted by PBM High level, project specific, tasks required for enterprise deployment: – CPRS portions that have been developed and need to be migrated to v29 of CPRS (was developed on v28 in Sandbox) – AudioCare telephone refill request system development needs to be changed from API to Cache and a plan for release needs to be negotiated with AudioCare – MHV portion of development needs to be completed – Six (6) month pilot at approximately six (6) sites and Class III to Class I verification performed prior to national release 2

4. VETERANS HEALTH ADMINISTRATION ISB Selection Criteria 3 CriteriaSee…Self-Assigned Score ComplianceSlide 41 Five-Year Net Operational Cost ChangeSlide 55 Implementation CostSlide 6-6 Clinical Impact (Broadness)Slide 710 Clinical Impact (Degree)Slide 710 Business Impact (Broadness)Slide 810 Business Impact (Degree)Slide 810 Patient SafetySlide 95 Patient ValueSlide 1010 Healthcare DisparitySlide 111 Summary Value = 1 * (19+36) = 55 Business Value = 5 + (-6) + 10 + 10 = 19 Clinical Value = 10 + 10 + 10 + 1 + 5 = 36

5. VETERANS HEALTH ADMINISTRATION Business Case – Compliance PARK is compliant with regulations, including patient safety -VistA Pharmacy, CPRS, and Audiocare portion of solution do not require 508 compliance -Future MHV development portion may require 508 compliance -Addresses medication reconciliation with regard to Meaningful Use, Affordable Care Act, and Joint Commission -PARK complies with patient safety requirements 4 Self Assigned Score: 1

6. VETERANS HEALTH ADMINISTRATION Business Case – 5 Year Net Operational Cost Change 5 In CY2010, 1.8% of the prescriptions filled at the pharmacy window were returned to stock because they were never picked up by the patient (unneeded)  Assumption: A similar fraction of new and renewal prescriptions filled through mail (CMOP and local) are unneeded Unlike the pharmacy window, unneeded prescriptions filled through the mail (CMOP and local) cannot be returned to stock The cost of filling these prescriptions, including the cost of the medication, labor, and shipping/overhead, are all wasted PARK would eliminate this waste and save VA approximately $107,838,460 over 5 years or $21,567,692 annually (see slide 13) Self Assigned Score: 5

7. VETERANS HEALTH ADMINISTRATION Business Case - Implementation Costs 6 Year 1Year 2Year 3Year 4Year 5 Pilot Phase$1,140,000$0 Deployment Phase$0$3,140,000$0 Annual Total$1,140,000$3,140,000$0 Cumulative Costs$1,140,000$4,280,000 Self Assigned Score: -6

8. VETERANS HEALTH ADMINISTRATION Business Case – Clinical Impact Broadness: PARK positively impacts three (3) clinical performance metrics 7 Self Assigned Score, Broadness: 10 Self Assigned Score, Degree: 10 Clinical Performance MetricDegree of Impact Communication about medications (NDPP) 30% improvement Discharge information (NDPP) 10% improvement Provider wait time 20 minutes or less (NDPP/OMB/PAR) 5% improvement Degree: PARK positively impacts these metrics in the following ways - Improves communication on medications among PACT team members - Improves quality of care by preventing medication errors - Improves accuracy of medication profiles (medication reconciliation) for clinical decision making - Eliminates Veteran confusion associated with receiving multiple bottles of the same medication - Limits adverse drug events and decreases patient misuse and abuse - Improves hospital admission/discharge communication on medications - Improves provider wait times by standardizing and streamlining medication reconciliation process

9. VETERANS HEALTH ADMINISTRATION Business Case – Business Impact Broadness: PARK positively impacts six (6) business performance metrics 8 Self Assigned Score, Broadness: 10 Self Assigned Score, Degree: 10 Degree: PARK positively impacts these metrics in the following ways - Improves accuracy of medication profiles (medication reconciliation) for clinical decision making - Standardizes and streamlines medication reconciliation process among providers - Improves data access and integrity with regard to medication profiles - Reduces eClaim fraud and medication errors - Reduces medication, labor, shipping, and overhead cost associated with unnecessary/unneeded prescription fills - Patient confusion due to receiving multiple bottles of the same medication - Decreases Veterans co-pay charges - Improves pharmacy wait times due to better prioritization of prescription fills - Improves provider wait times by standardizing and streamlining medication reconciliation process - Improves accessibility to prescription refills and increases availability of medication for on-demand ordering Business Performance MetricDegree of Impact Improved accuracy of decision making (quality of work) 20% improvement Standardization of best practices (quality of work) 10% improvement Enhanced data access, integrity, or aggregation (quality of work) 5% improvement Reduces program or organizational risk (quality of work) 35% improvement Reduces costs (VA staff efficiency or workflow) 15% improvement Improves the environment of care (Veteran/beneficiary’s experience) 5% improvement

10. VETERANS HEALTH ADMINISTRATION Business Case - Patient Safety PARK demonstratively improves patient safety -Improves accuracy of medication profiles (medication reconciliation) for clinical decision making -Improves quality of care by preventing medication errors -Limits adverse drug events and decreases patient misuse and abuse -Eliminates Veteran confusion due to receiving multiple bottles of the same medication Evaluation Criteria Scored -10 to 10 where -10 is severe decrease in patient safety, 0 is no change in patient safety and +10 is very strong impact in patient safety 1.Demonstratively reduces preventative harm in this population: 6 2.Reduces mortality and morbidity in this population: 2 3.Improves patient safety by demonstratively reducing the chance of human error: 7 9 Self Assigned Score: 5

11. VETERANS HEALTH ADMINISTRATION Business Case – Patient Value PARK significantly increases patient satisfaction -Decreases Veterans co-pay charges by $2.7 million annually (see slide 15) -Improves pharmacy wait times by 20% -Improves provider wait times by 10% -Improves accessibility to prescription refills -Increases availability of medication for on-demand ordering 10 Self Assigned Score: 10

12. VETERANS HEALTH ADMINISTRATION Business Case – Healthcare Disparity PARK does not address a healthcare disparity 11 Self Assigned Score: 1

13. VETERANS HEALTH ADMINISTRATION Back Up Slides 12

14. VETERANS HEALTH ADMINISTRATION Other Considerations - Calculating the Annual Cost Savings for PARK 13 Data ElementAmount Total number of new and renewal Rx filled by mail annually 1 (FY10)49,776,000 Percentage of Rx that are unnecessary/unused by patient 2 1.8% Number of unnecessary Rx filled through mail annually895,968 Average cost of filling an Rx through mail Medication 3 (FY12) Labor 4 (FY10) Shipping/Overhead 4 (FY10) $24.63 $21.39 $0.99 $2.25 Annual cost savings that can be realized by not filled unwanted/unneeded Rx through mail Medication Labor Shipping/Overhead $22,067,692 $19,164,756 $887,008 $2,015,928 Annual cost savings less operational expenses for sustainment and increased capability ($500k) $21,567,692 Net operational cost savings over5 year period$107,838,460

15. VETERANS HEALTH ADMINISTRATION Other Considerations – Environmental Impact PARK will: -Reduce hazardous waste reaching landfills and major water sources -Decrease availability of unused medication for accidental ingestion or poisoning and drug diversion Over the past 2 ½ years, the DEA has held five Prescription Drug Take-Back Days which provide the public with a way to dispose of unwanted, unused, and expired prescription medications Through these events, the DEA has collected more than 2.8 million pounds (1,409 tons) of prescription medications The prescription medication collected through the Drug Take-Back Initiative likely represents a small fraction of the unwanted, unused, or expired medication 14

16. VETERANS HEALTH ADMINISTRATION Other Considerations – Avoided Co-Pay Cost to Veteran 15  Veterans cannot be reimbursed for co-pays they are charged for unwanted/unused prescriptions. PARK will save Veterans $2,723,744 annually in unnecessary co-pays.  Assumption: As with the previous cost savings estimate, we are assuming that the percentage of unnecessary prescriptions issued through mail (CMOP and local) are similar to the rate observed at the pharmacy window (1.8%).  Unlike the pharmacy window, unneeded prescriptions filled through the mail (CMOP and local) cannot be returned to stock.  The co-pay associated with filling these prescriptions are unnecessary. PARK would allow Veterans to avoid these co-pays. *Veteran responsibility for co-pay is based on their service-connected disability rating and/or the condition being treated by the Rx. Data ElementAmount Number of new or renewal Rx filled by mail annually that require a Veteran co-pay 1 (FY10) 18,914,880 Percentage of Rx that are unnecessary/unused by patient 2 1.8% Number of Rx filled annually through mail that require a co-pay but are non needed 340,468 Average Rx co-pay $8 Veteran co-pay costs for unneeded Rx that can be avoided with Park a Prescription* $2,723,744

17. VETERANS HEALTH ADMINISTRATION Other Considerations - CPRS New Orders Screenshot 16

18. VETERANS HEALTH ADMINISTRATION Other Considerations - CPRS Meds Tab (New Status) Screenshot 17