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9th Annual Pharmacy InformaticsConferenceVA Pharmacy InformaticsModernization, MINISTRATION

Overview of the MeetingVETERANS HEALTH ADMINISTRATION

Overview onGovernanceVETERANS HEALTH ADMINISTRATION

INNOVATION

Innovation cont. 1977 - MUMPS Developed VA Massachusetts General Hospital UtilityMulti-Programming System (MUMPS), aprecursor to VistA, developed by theComputer Assisted System Staff (CASS) Team.VETERANS HEALTH ADMINISTRATION

MUMPS Innovation vs Governance1989 - Apples Installed at AtlantaAutomated, Prescription Processing,Editing, StoragePunch card system1972- Cost Benefit Study recommendedExpansion across the countryAPPLES, Super APPLES, DIMPLESVarious modifications at Dallas,Chicago WS, Minneapolis, Wadsworth1980 - COMSS Installed at Chicago hospitalsOutpatient Unit Dose, IV’s, TPN’s,Interventions etc.Dr. Custis selected DHCP for VA computersystem utilizing the Pharmacy MinicomputerVETERANS HEALTH ADMINISTRATION

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

Innovation1999 - CPRS fully implemented CPRS implemented at all VA medical facilities. CPRS' majorfunctionalities 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) andhealth summaries, Provider order entry for all clinical services and departments, and Clinical decision support with reminders, real-time clinical alertsystems, notification systems, order checking, and diseasemanagement featuresVETERANS HEALTH ADMINISTRATION

Pharmacy Service becomes Pharmacy BenefitsManagement (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, 1997VETERANS HEALTH ADMINISTRATION

Innovation continued– Pharmacy 4 software packages Drug & Pharmaceutical Product Management (DPPM) became thePBM 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 ProgramVETERANS HEALTH ADMINISTRATION

Pharmacy and COTS PADE, and OPAI Interfaces to AutomatedDispensing Devices (i.e. ScriptPro, Optifill,Pyxis, Omnicell) MOCHA uses First Data BankVETERANS HEALTH ADMINISTRATION

Trend Analysis:Model Usage TrendingTop Vendor Usage Trending*(Between 2015 and 2016 Assessments)Widely Used VendorsArea of Automation2015 Assessment2016 AssessmentScriptPro (177 users)ScriptPro (158 user)Omcicell (89 users)Omcicell (79 users)ABTG (58 users)ARXiUM (51 users)Commercial Products (COTS)Carefusion (30 users)Omnicell (36 users)Automated Controlled Substance StorageCarefusion (28 users)Omnicell (23 users)Qmatic (4 users)ScriptPro Notice Board (18 users)Other (5 users)Other (16 users)Aesynt (11 users)Omnicell (10 users)ScriptPro (5 users)Telepharmacy (5 users)Pick Point (7 users)Outpatient PrescriptionAutomated Dispensing CabinetsInpatient Unit Dose FillWill Call System- NotificationWill Call System- Pick upAutomated Inventory ManagementTelepharmacyVETERANS HEALTH ADMINISTRATION11

Pharmacy Innovation Current Pharmacy Re-engineering ProgramsBCMA EnhancementsCPRS Enhancements V32?E-Pharmacy Claims ProcessingState Prescription Drug MonitoringOne VA PharmacyVistA Enhancements – Clinical RemindersVirtual Education and TrainingVETERANS HEALTH ADMINISTRATION

Analytics and Reporting Focus on Patient Safety, Outcomes,Pharmacoeconomics, Inventory andPurchasing– FileMan Tools– VADERS– Utilization Reports VistA (AMIS) CDW and SQL Proclarity/PyramidVETERANS HEALTH ADMINISTRATION13

InnovationPRE Functional Architecture 2004Veteran PopulationSetDirectionAnd GoalsMeasureFor GoalAttainmentVAVHAPHARMACYMonitor Clinical AdministerOrderVeteranVeteranVeteran Valued ProcessesManagePharmacy Enterprise Product SystemManageInventoryManageToolsContinuous Improvement FrameworkProvide Metrics and Methods for Continuous Process ImprovementVETERANS HEALTH ADMINISTRATION

PRE IMS (High Level)VETERANS HEALTH ADMINISTRATION

Slide with way too much informationto readVETERANS HEALTH ADMINISTRATION

Slide with a huge relationship diagramthat is not readableVETERANS HEALTH ADMINISTRATION

Innovation Choice In Bound e PrescribingExternal to VAChange Healthcare10HTTPS, 2-way S SL/TLSDAS External GatewayeRx InboundProxy S erviceeRx OutboundProxy S erviceDASeRx StatusProxy S erviceJMS96PentahoDI ServicesPentahoServerDatabase(RHEL NM)7eRx ReverseProxyInboundeRxSq lNe tApach eSSOiMVI3Sq lNe t2eRx ReceiverServiceHTTPS11IAMJMSInbound eRxProcess H ubHD RHTTPS12Enrollment a ndEligibility SystemTCPeRx(RHEL VM)13eRx Web Cons oleWebLogic51VA EnterpriseSource ServicesHTTPSVistA LinkPharmacy App.AdminsVA eRx UserseRx RPCPRE Encapsu lation4eRxHoldingQueueVistA OPVistAVETERANS HEALTH ADMINISTRATIONHTTPS8VA

Standardization in Pharmacy PRE Encapsulation of Pharmacy DataFirst Data Bank Drug CodesTerminology – RxNormHL7NCPDPFHIRArchitectural changes in Patch Process underPREVETERANS HEALTH ADMINISTRATION

Governance 2004 - IT moves from VHA IT staff moves from Veterans HealthAdministration (VHA) to its own department,led by VA Chief Information Officer (CIO) withbudget authority.VETERANS HEALTH ADMINISTRATION

Governance 2010 2010 Regional reorganization of OIT VA begins regional reorganization of its Officeof Information and Technology (OIT).VETERANS HEALTH ADMINISTRATION

GovernanceOI&T Changes with Major Impacts1977 - MUMPS DevelopedJune 1981 - MUMPS becomes VistA1994 1999 - CPRS fully implemented2002 -IT Programs centralizedNovember 2003 - My HealtheVet launched2004 - IT moves from VHA2007 - IT organizational structure approvedOctober 2004 - BHIE enables two-way data exchangebetween VA and DoD – December 2007 - Data Repository launched April 2009 - VLER introduced - Integration VETERANS HEALTH ADMINISTRATION

OI&T GovernanceJune 2009 - PMAS Initiated2009 - IT Consolidation completed2010 Regional reorganization of OITOctober 2011 - OneVA re-establishedMarch 2012 - CRISP launchedOctober 2012 - VistA Open StandardizationProject implemented May 2013 PIV card-based access implemented VETERANS HEALTH ADMINISTRATION

OI&T Governance cont. September 2015 – VistA Evolution/VistA 4Feature Set #2 projected release Oct 2015 - Major Transformation InitiativeAnnounced January 2016 - VIP replaces PMAS April 2016 - Establishment of EPMO December 2016 - Digital Health PlatformannouncedVETERANS HEALTH ADMINISTRATION

Governance and OrganizationalChanges Impacts to Innovation OI&T Regionalization removed pharmacyaccess to certain VistA programs resultinglimited ability to perform analytics, reporting,and care management. Security while beneficial has causedchallenges, i.e. PIV cards, CRISP requirementsVETERANS HEALTH ADMINISTRATION

Interoperability/Data SharingTransformationsEfforts October 2004 - BHIE enables two-way data exchangebetween 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 BeStopped w/CernerVETERANS HEALTH ADMINISTRATION26

Interoperability/Data SharingTransformations Efforts cont. December 2013 - VistA Evolution launched –Integrated System (eHMP) – Stopped Open Source Electronic Health Record September 2014 - VA-Walgreens partnershipestablished - complete April 2015 - State Prescription MonitoringProgram – data sharing – CompleteVETERANS HEALTH ADMINISTRATION27

A large Illegible diagramVETERANS HEALTH ADMINISTRATION28

One SystemVA and DoD MHS Genesis The Department of Veterans Affairs (VA) isundertaking an enterprise-wide ElectronicHealth Record Modernization (EHRM) effortthrough the procurement of the Cernercommercial electronic health record (EHR)software and related support services. TheDepartment of Defense (DoD) is currentlydeploying the Cerner Millennium EHR solutionand associated services under the branding“MHS Genesis”VETERANS HEALTH ADMINISTRATION

GovernanceVHA Office of Health Informatics- 2011 OIA was formed in February 2011 to integrate strengths inhealth informatics, data management, performancemeasurement, and analysis so that the Veterans HealthAdministration (VHA) could more effectively collect and useinformation at the point of care, support continuousimprovement, and empower health care delivery teams. SIM Mission: Facilitate sound decision making for thedevelopment, acquisition, and maintenance of healthfocused IT investments by providing leadership with acomprehensive understanding of needed VHA businesscapabilities including business requirements, processes,information needs, IT strategy and priorities, andinvestment analysis.VETERANS HEALTH ADMINISTRATION

VHA Governance and Standardization Business ArchitectureInvestment Governance ServicesOpen Source ManagementRequirements Development and Management A complex process for receiving approval andfunding for software development. New Service Request Process Clinical Capability Management BoardsVETERANS HEALTH ADMINISTRATION

OIAVETERANS HEALTH ADMINISTRATION

Innovation and GovernanceVETERANS HEALTH ADMINISTRATION

VHA IT GovernanceVETERANS HEALTH ADMINISTRATION

OIA InnovationNew Service Request Process - 0411062005010720050411UPN in GIPAlerts for Non-Refilled MedicationsASISTS GUI InterfaceASISTS Occupational Health DatabaseEnhancements to the Prosthetics Software PackageInpatient Pharmacy Orders HL7 InterfaceNutrition & Food Service 'Tickler' Screening ReportProgram Enhancement for Outpatient MealsPhlebotomy Capture on Order Entry EnhancementDietetics Multidivisional Enhancements (Menu Cycles)QUASAR-GUI InterfaceAdministrative Tab added in CPRSMARRCCLinking medication ordersText Search & Progress Note Construction Tool CAPRI/CPRSWireless BloodCareClinical Reminders creating dynamic URL linksWireless CareView by Care Fusion, Inc.Surgery Implant RegistryRe-work of Additional Signer functionalityPrivacy Issues with TIU Alert ProcessingAccess Authority RegistryRemoving address requirement to transmit workloadVETERANS HEALTH ADMINISTRATIONNew ServiceNew ServiceNew ServiceNew ServiceNew ServiceNew ServiceNew ServiceNew ServiceNew ServiceNew ServiceNew ServiceNew ServiceNew ServiceNew ServiceNew ServiceNew ServiceNew ServiceNew ServiceNew ServiceNew ServiceNew ServiceNew ServiceNew ServiceProsthetics,InpatientAutomated SafetyAutomated SafetyProsthetics,Bar CodeNutrition & FoodComputerizedLaboratory,Nutrition & FoodComputerizedComputerizedNew Application,ComputerizedCompensationBar CodeComputerizedBar CodeProsthetics,ComputerizedText IntegrationTo be determined,Registration,This is a request to modify VistA's GenericThe development of a software program or similarThe goal of this request is to develop a GraphicThe goal of this request is to develop anFrederick Downs, Jr., VACO, VHA Prosthetics ServiceAnn Chu, Programmer at Information ResourceEnhance the N&FS Package to enable printing of aCreate an enhancement to N&FS Package to allowDr. Theodore Beals, VACO (115) submitted thisProvide the ability to have multiple menu cyclesStephen Gonzenbach, Ed.D., Chief of Audiology, NewGail Graham of the Office of InformationLarry N. Long, MBA, CTRS, and Director, RecreationalThe National BCMA Joint Program Office isDr. Kolodner is requesting an evaluation of portingThis is a commercial technology request toBrad Goo, Data Warehousing Programmer, VISN 21,To be able to provide wireless access to patientFrederick Downs, Chief Consultant, Prosthetics hasLinda Nugent, Office of Health Data & Informatics,The purpose of this request is to analyze the level ofDr. Jonathan Perlin, Acting Under Secretary forLynne 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 systemby adopting the electronic health record (EHR)system that is being deployed by DOD, whichat its core consists of Cerner Millennium.VETERANS HEALTH ADMINISTRATION

VA EHR Modernization Plan The Undersecretary of Health and Chief Information Officer will serve asthe Executive Sponsors and will lead the EHR modernization (EHRM)effort. EHRM will have a dedicated Program Executive Office (PEO), whichwill be staffed with VA’s most knowledgeable technical and functionalsubject matter experts. VA is identifying funding for EHRM, and is entering contract negotiationswith Cerner to acquire the EHR system being deployed by DOD. VA intendsto work with DOD, Cerner, and other interested parties in efforts toachieve seamless care across America, ensuring connectivity with VAsacademic affiliates and community care partners. VA has unique needs that may differ from the DOD requirements. As theVA adopts the EHR that DOD uses, we will also build upon it to meet VAunique requirements while implementing a single common system formanaging patients.VETERANS HEALTH ADMINISTRATION

Electronic Health RecordModernization (EHRM)VETERANS HEALTH ADMINISTRATION

TransformationVETERANS HEALTH ADMINISTRATION

Impact to VistA PharmacyNear Term Replacement of VistA? Replacement of Interfaces such as OPAI and PADEwith HealthShare/Health Connect(Regionalization) Replacement of Purchasing Supply ChainManagement System with DMLSS Focus on COTS products– Light House Lab– VA Open Application Programming Interface Re-Organization of OI&T and VHAVETERANS HEALTH ADMINISTRATION

InnovationVETERANS HEALTH ADMINISTRATION

ModernizationVETERANS HEALTH ADMINISTRATION

GovernanceVETERANS HEALTH ADMINISTRATION

StandardizationVETERANS HEALTH ADMINISTRATION

Standardization Impact on Innovation Changes in OI&T Standardization and GovernanceRequirements can result in delays in innovation example––––Vitria Interface shut down WDDEeMI started and shut downVIE converting to HealthShare - 2018HealthShare/Health Connect causing delay inPharmacy AMPL GUI – completion date - ?VETERANS HEALTH ADMINISTRATION

Governance – Will it Rain on ourInnovationVETERANS HEALTH ADMINISTRATION

Transformation Impact toVA Pharmacy Informatics WorkforcePutting Patients First Standardization and Governance has led to adecreased ability to innovate and have accessto health care technology at the local level If VA moves to Cerner and other OI&Tchanges, focus will be on configuration, butlocal informatics staff will likely have lessaccess to technology controlsVETERANS HEALTH ADMINISTRATION

PBM role is to support the VAMC staff inmeeting goals to provide pharmaceutical care toour patients– Oversight of Technology Development– Technology Governance and Policy– Advocacy– Resources Patient Safety Benefit Realization Metrics Analytics and Reporting Finding a path to fundingVETERANS HEALTH ADMINISTRATION48

PBM role is to support the VAMC staff in meeting goalsto provide pharmaceutical care to our patients– Testing– Subject Matter Experts– Communications– Training and Education– Support for Implementation and DeploymentPartnership and Collaboration with OI&T, OIIG,Federal Agencies, Commercial Vendors, OSEHRAVETERANS HEALTH ADMINISTRATION49

Challenges to Transitioning to aVA/DoD One Record System CMOP (Consolidated Mail Order Pharmacy)Interface to COTS Transition from First DataBank to MULTUM Identification of a process to ensure MedicationOrder Checks occur and meet Patient SafetyRequirements Data Migration and Integration Pharmacy Automated Interfaces Transition of power of the sites ability to configureand control to an enterprise level.VETERANS HEALTH ADMINISTRATION

Challenges to Transitioning to aVA/DoD One Record System cont. BCMA no longer a part of pharmacy systemData MigrationTesting, Deployment, ImplementationChanges to WorkPolicies and RegulationsIFCAP, Purchasing, ContractingInventoryVETERANS HEALTH ADMINISTRATION51

Overcoming Challenges Focus on benefits to the PatientSeat 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, metricsResearch and documentHow does it help patients/Veterans and or our organization, always keeppatient’s first Ask until you find the person with the answer or who you can give theanswer to: No is an answer but so is Yes. When its safe - ask for forgiveness instead of permission, or build it andthey will come Follow the money: identify a pathway to have your innovation funded– (this may change due to governance changes)VETERANS HEALTH ADMINISTRATION

QuestionsVETERANS HEALTH ADMINISTRATION53

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 uniqu