Conference VA Pharmacy Informatics Modernization ...

VETERANS HEALTH ADMINISTRATION

9th Annual Pharmacy Informatics Conference

VA Pharmacy Informatics Modernization, Transformation,

Innovation

March 2018


Overview of the Meeting


Overview

• Modernization • Transformation • Innovation • Standardization • Governance

INNOVATION


Innovation cont.

• 1977 - MUMPS Developed • VA Massachusetts General Hospital Utility

Multi-Programming System (MUMPS), a precursor to VistA, developed by the Computer Assisted System Staff (CASS) Team.


MUMPS Innovation vs Governance 1989 - Apples Installed at Atlanta

Automated, Prescription Processing, Editing, Storage Punch card system

1972- Cost Benefit Study recommended Expansion across the country APPLES, Super APPLES, DIMPLES Various modifications at Dallas, Chicago WS, Minneapolis, Wadsworth 1980 - COMSS Installed at Chicago hospitals Outpatient Unit Dose, IV’s, TPN’s, Interventions etc. Dr. Custis selected DHCP for VA computer system utilizing the Pharmacy Mini-computer


Pharmacy Innovation

• DHCP OP version 1.0 installed 1982 • OP version 2.0 installed in all VAMC’s 1985 • IV’s 1983-85 • Ward Stock Automatic Replenishment 1984 • Unit Dose 1986 • DHCP expanded to 13 individual Pharmacy

Modules


Innovation

1999 - CPRS fully implemented

• CPRS implemented at all VA medical facilities. CPRS' major functionalities included:

• A clinical data repository with privacy protection, • Data retrieval and display, • Document entry with role-based business rules, • Problem lists, medication lists, reports (including radiology) and

health summaries, • Provider order entry for all clinical services and departments, and • Clinical decision support with reminders, real-time clinical alert

systems, notification systems, order checking, and disease management features


Pharmacy Service becomes Pharmacy Benefits

Management (PBM) in 1995 (John Ogden, Michael Valentino)

• Procurement standardization

– Utilization monitoring – Pharmacy Service Policies Standards – Defined Drug Benefit

• VA National Formulary – 22 VISN Formularies, 1996 – VA National Formulary, 1997


Innovation continued

– Pharmacy 4 software packages • Drug & Pharmaceutical Product Management (DPPM) became the

PBM extract – 1999 to Present– Patient Specific Data – ProClarity datacubes

• Controlled Substances Version 3.0 – Wireless Proof of concept using 802.11A standard

• Drug Accountability – Electronic Updates from Prime Vendor

• Bar Code Medication Administration – Fully implemented 2000 – Version 3.0 – Pinnacle Award 2002

• Consolidated Mail Outpatient Pharmacy Program


Pharmacy and COTS

• PADE, and OPAI Interfaces to Automated Dispensing Devices (i.e. ScriptPro, Optifill, Pyxis, Omnicell)

• MOCHA uses First Data Bank


Trend Analysis: Model Usage Trending

Widely Used Vendors

Area of Automation 2015 Assessment 2016 Assessment

Outpatient Prescription ScriptPro (177 users) ScriptPro (158 user)

Automated Dispensing Cabinets Omcicell (89 users) Omcicell (79 users)

Inpatient Unit Dose Fill ABTG (58 users) ARXiUM (51 users)

Commercial Products (COTS) Carefusion (30 users) Omnicell (36 users)

Automated Controlled Substance Storage Carefusion (28 users) Omnicell (23 users)

Will Call System- Notification Qmatic (4 users) ScriptPro Notice Board (18 users)

Will Call System- Pick up Other (5 users) Other (16 users)

Automated Inventory Management Aesynt (11 users) Omnicell (10 users)

Telepharmacy ScriptPro (5 users) Telepharmacy (5 users) Pick Point (7 users)

Top Vendor Usage Trending* (Between 2015 and 2016 Assessments)

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Pharmacy Innovation Current

• Pharmacy Re-engineering Programs • BCMA Enhancements • CPRS Enhancements V32? • E-Pharmacy Claims Processing • State Prescription Drug Monitoring • One VA Pharmacy • VistA Enhancements – Clinical Reminders • Virtual Education and Training


Analytics and Reporting

• Focus on Patient Safety, Outcomes, Pharmacoeconomics, Inventory and Purchasing – FileMan Tools – VADERS – Utilization Reports

• VistA (AMIS) • CDW and SQL • Proclarity/Pyramid

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Innovation PRE Functional Architecture 2004

Value

MeasureFor GoalAttainment

SetDirectionAnd Goals

Continuous Improvement FrameworkProvide Metrics and Methods for Continuous Process Improvement

Veteran Population

VHA

VA

Veteran

Veteran Valued Processes

RecordOrder

Dispense Order

ActivateOrder

Manage Inventory

PHARMACY

Monitor Clinical Activity

Veteran

Administer Order

ManageTools

ManagePharmacy Enterprise Product System


PRE IMS (High Level)


Slide with way too much information to read


Slide with a huge relationship diagram that is not readable


Innovation Choice In Bound e Prescribing

VA

eRx(RHEL VM)

External to VAChange Healthcare

DAS External Gateway

10

HTTPS

HTTPS, 2-way SSL/TLS

Database(RHEL NM)

InboundeRx

6

2

Apache

eRx Reverse Proxy

3

DAS 9

eRx InboundProxy Service

eRx OutboundProxy Service

eRx StatusProxy Service

WebLogic

Inbound eRxProcess Hub

eRx Web Console

eRx Receiver Service

5

SqlNet

HTTPS

PentahoServer

Pentaho DI Services

7

SqlNet

VA Enterprise Source Services

Enrollment and Eligibility System

HDR

IAM

MVI

11

SSOi

13

12

TCP

VistA

VistA OP

PRE Encapsulation

eRx RPCeRx

Holding Queue

VistA Link

8

VA eRx Users

Pharmacy App. Admins

4

1

JMS

JMS

HTTPS

HTTPS


Standardization in Pharmacy

• PRE Encapsulation of Pharmacy Data • First Data Bank Drug Codes • Terminology – RxNorm • HL7 • NCPDP • FHIR • Architectural changes in Patch Process under

PRE


Governance

• 2004 - IT moves from VHA • IT staff moves from Veterans Health

Administration (VHA) to its own department, led by VA Chief Information Officer (CIO) with budget authority.


Governance 2010

• 2010 Regional reorganization of OIT • VA begins regional reorganization of its Office

of Information and Technology (OIT).


Governance OI&T Changes with Major Impacts

• 1977 - MUMPS Developed • June 1981 - MUMPS becomes VistA • 1994 1999 - CPRS fully implemented • 2002 -IT Programs centralized • November 2003 - My HealtheVet launched • 2004 - IT moves from VHA • 2007 - IT organizational structure approved • October 2004 - BHIE enables two-way data exchange

between VA and DoD – • December 2007 - Data Repository launched • April 2009 - VLER introduced - Integration


OI&T Governance

• June 2009 - PMAS Initiated • 2009 - IT Consolidation completed • 2010 Regional reorganization of OIT • October 2011 - OneVA re-established • March 2012 - CRISP launched • October 2012 - VistA Open Standardization

Project implemented • May 2013 PIV card-based access implemented


OI&T Governance cont.

• September 2015 – VistA Evolution/VistA 4 Feature Set #2 projected release

• Oct 2015 - Major Transformation Initiative Announced

• January 2016 - VIP replaces PMAS • April 2016 - Establishment of EPMO • December 2016 - Digital Health Platform

announced


Governance and Organizational Changes Impacts to Innovation

• OI&T Regionalization removed pharmacy access to certain VistA programs resulting limited ability to perform analytics, reporting, and care management.

• Security while beneficial has caused challenges, i.e. PIV cards, CRISP requirements


Interoperability/Data Sharing-

Transformations Efforts

• October 2004 - BHIE enables two-way data exchange between VA and DoD – Integrated System – Complete – to be stopped

• 2006 Clinical Health Data Repository (CHDR) - Complete to be stopped

• April 2009 - VLER introduced – Integration – Complete • 2010 VistA Web and CPRS w/RDV • 2011 VA/DoD Integrated Electronic Health Record –

Single System - Stopped • July 2013 – Joint Legacy Viewer – Complete – To Be

Stopped w/Cerner

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Interoperability/Data Sharing-Transformations Efforts cont.

• December 2013 - VistA Evolution launched –

Integrated System (eHMP) – Stopped • Open Source Electronic Health Record • September 2014 - VA-Walgreens partnership

established - complete • April 2015 - State Prescription Monitoring

Program – data sharing – Complete

27


A large Illegible diagram

28


One System VA and DoD MHS Genesis

• The Department of Veterans Affairs (VA) is undertaking an enterprise-wide Electronic Health Record Modernization (EHRM) effort through the procurement of the Cerner commercial electronic health record (EHR) software and related support services. The Department of Defense (DoD) is currently deploying the Cerner Millennium EHR solution and associated services under the branding “MHS Genesis”


Governance VHA Office of Health Informatics- 2011

• OIA was formed in February 2011 to integrate strengths in health informatics, data management, performance measurement, and analysis so that the Veterans Health Administration (VHA) could more effectively collect and use information at the point of care, support continuous improvement, and empower health care delivery teams.

• SIM Mission: Facilitate sound decision making for the development, acquisition, and maintenance of health-focused IT investments by providing leadership with a comprehensive understanding of needed VHA business capabilities including business requirements, processes, information needs, IT strategy and priorities, and investment analysis.


VHA Governance and Standardization

• Business Architecture Investment Governance Services Open Source Management Requirements Development and Management

• A complex process for receiving approval and funding for software development.

• New Service Request Process • Clinical Capability Management Boards

https://vaww.vha.esp.va.gov/sites/BA/default.aspx

http://vaww.ehealth.va.gov/EHEALTH/investment-governance-services.asp

https://vaww.vaco.portal.va.gov/sites/OHIA/sim/OpenSourceManagement/Pages/default.aspx

https://vaww.vashare.vha.va.gov/sites/RDM/SitePages/Home.aspx


OIA


Innovation and Governance


VHA IT Governance


OIA Innovation New Service Request Process - 2900

19990303 19990303 UPN in GIP New Service Prosthetics, This is a request to modify VistA's Generic 19990603 19990603 Alerts for Non-Refil led Medications New Service Inpatient The development of a software program or similar 19991003 19991003 ASISTS GUI Interface New Service Automated Safety The goal of this request is to develop a Graphic 19991004 19991004 ASISTS Occupational Health Database New Service Automated Safety The goal of this request is to develop an 19991211 19991211 Enhancements to the Prosthetics Software Package New Service Prosthetics, Frederick Downs, Jr., VACO, VHA Prosthetics Service 20000801 20000801 Inpatient Pharmacy Orders HL7 Interface New Service Bar Code Ann Chu, Programmer at Information Resource 20000901 20000901 Nutrition & Food Service 'Tickler' Screening Report New Service Nutrition & Food Enhance the N&FS Package to enable printing of a 20001011 20001011 Program Enhancement for Outpatient Meals New Service Computerized Create an enhancement to N&FS Package to allow 20010302 20010302 Phlebotomy Capture on Order Entry Enhancement New Service Laboratory, Dr. Theodore Beals, VACO (115) submitted this 20010712 20010712 Dietetics Multidivisional Enhancements (Menu Cycles) New Service Nutrition & Food Provide the abil ity to have multiple menu cycles 20011002 20011002 QUASAR-GUI Interface New Service Computerized Stephen Gonzenbach, Ed.D., Chief of Audiology, New 20011007 20011007 Administrative Tab added in CPRS New Service Computerized Gail Graham of the Office of Information 20030901 20030901 MARRCC New Service New Application, Larry N. Long, MBA, CTRS, and Director, Recreational 20031204 20031204 Linking medication orders New Service Computerized The National BCMA Joint Program Office is 20040204 20040204 Text Search & Progress Note Construction Tool CAPRI/CPRS New Service Compensation Dr. Kolodner is requesting an evaluation of porting 20040309 20040309 Wireless BloodCare New Service Bar Code This is a commercial technology request to 20040409 20040409 Clinical Reminders creating dynamic URL l inks New Service Computerized Brad Goo, Data Warehousing Programmer, VISN 21, 20040419 20040419 Wireless CareView by Care Fusion, Inc. New Service Bar Code To be able to provide wireless access to patient 20040601 20040601 Surgery Implant Registry New Service Prosthetics, Frederick Downs, Chief Consultant, Prosthetics has 20040803 20040803 Re-work of Additional Signer functionality New Service Computerized Linda Nugent, Office of Health Data & Informatics, 20041106 20041106 Privacy Issues with TIU Alert Processing New Service Text Integration The purpose of this request is to analyze the level of 20050107 20050107 Access Authority Registry New Service To be determined, Dr. Jonathan Perlin, Acting Under Secretary for 20050411 20050411 Removing address requirement to transmit workload New Service Registration, Lynne Harbin, HEC Assistant Director, Project


Electronic Health Record Modernization (EHRM) Governance Driving Innovation

• In order to ensure seamless care for Veterans,

VA will move toward a single common system by adopting the electronic health record (EHR) system that is being deployed by DOD, which at its core consists of Cerner Millennium.


VA EHR Modernization Plan

• The Undersecretary of Health and Chief Information Officer will serve as the Executive Sponsors and will lead the EHR modernization (EHRM) effort. EHRM will have a dedicated Program Executive Office (PEO), which will be staffed with VA’s most knowledgeable technical and functional subject matter experts.

• VA is identifying funding for EHRM, and is entering contract negotiations with Cerner to acquire the EHR system being deployed by DOD. VA intends to work with DOD, Cerner, and other interested parties in efforts to achieve seamless care across America, ensuring connectivity with VAs academic affiliates and community care partners.

• VA has unique needs that may differ from the DOD requirements. As the VA adopts the EHR that DOD uses, we will also build upon it to meet VA unique requirements while implementing a single common system for managing patients.


Electronic Health Record Modernization (EHRM)


Transformation


Impact to VistA Pharmacy Near Term

• Replacement of VistA? • Replacement of Interfaces such as OPAI and PADE

with HealthShare/Health Connect (Regionalization)

• Replacement of Purchasing Supply Chain Management System with DMLSS

• Focus on COTS products – Light House Lab – VA Open Application Programming Interface

• Re-Organization of OI&T and VHA


Innovation


Modernization


Governance


Standardization


Standardization Impact on Innovation

• Changes in OI&T Standardization and Governance Requirements can result in delays in innovation

• example – Vitria Interface shut down WDDE – eMI started and shut down – VIE converting to HealthShare - 2018 – HealthShare/Health Connect causing delay in

Pharmacy AMPL GUI – completion date - ?


Governance – Will it Rain on our Innovation


Transformation Impact to VA Pharmacy Informatics Workforce

Putting Patients First

• Standardization and Governance has led to a decreased ability to innovate and have access to health care technology at the local level

• If VA moves to Cerner and other OI&T changes, focus will be on configuration, but local informatics staff will likely have less access to technology controls


PBM role is to support the VAMC staff in

meeting goals to provide pharmaceutical care to our patients

– Oversight of Technology Development – Technology Governance and Policy – Advocacy – Resources

• Patient Safety • Benefit Realization Metrics • Analytics and Reporting • Finding a path to funding

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PBM role is to support the VAMC staff in meeting goals to provide pharmaceutical care to our patients

– Testing – Subject Matter Experts – Communications – Training and Education – Support for Implementation and Deployment Partnership and Collaboration with OI&T, OIIG, Federal Agencies, Commercial Vendors, OSEHRA

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Challenges to Transitioning to a VA/DoD One Record System

•CMOP (Consolidated Mail Order Pharmacy) Interface to COTS

•Transition from First DataBank to MULTUM • Identification of a process to ensure Medication Order Checks occur and meet Patient Safety Requirements Data Migration and Integration

•Pharmacy Automated Interfaces •Transition of power of the sites ability to configure and control to an enterprise level.


Challenges to Transitioning to a VA/DoD One Record System cont.

• BCMA no longer a part of pharmacy system • Data Migration • Testing, Deployment, Implementation • Changes to Work • Policies and Regulations • IFCAP, Purchasing, Contracting • Inventory

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Overcoming Challenges • Focus on benefits to the Patient • Seat at the table

– Make friends and find partners – When you’re the smartest person in the room speak up

• Follow the Money –Connected Care, EHRM, OI&T, IPO, VAMC • Demonstrate Value

– Evidence, metrics – Research and document – How does it help patients/Veterans and or our organization, always keep

patient’s first • Ask until you find the person with the answer or who you can give the

answer to: No is an answer but so is Yes. • When its safe - ask for forgiveness instead of permission, or build it and

they will come • Follow the money: identify a pathway to have your innovation funded

– (this may change due to governance changes)


Questions

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