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

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

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, http://www.pbm.va.gov/Default.aspx

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 http://en.wikipedia.org/wiki/Health_informatics Discipline at the intersection of information science, computer science and health care

(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.  

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)

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

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:      https://vapreapp1.aac.va.gov:8443/ct/public/ 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.

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

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

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

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

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

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) 1999. 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: http://vssc.med.va.gov/. #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 2007. The reports are located on the VA intranet at the following link: http://vaww.national.cmop.va.gov/PBM/National%20Formulary/Forms/AllItems.aspx. #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: https://medora.va.gov/adr. 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: http://vaww.vhaco.va.gov/HDI/oipatientsafety.asp. Survey next

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 2012. 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 2012. 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: http://vssc.med.va.gov/. #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: http://vssc.med.va.gov/.

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.

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

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

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.

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

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.

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

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.

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

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