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Pharmacy-driven Transformation

April 2009 Community Call

Presenters

• Terry Meehan, Medsphere

• Roy Gryskevich, Medsphere

• Larry Washington, Medsphere

• Joe Kiowski, Midland Memorial Hospital

• Randy Adams, Midland Memorial Hospital

• Stephanie Harper, Medsphere

• Janine Powell, Medsphere

• Jon Tai, Medsphere

• George Lilly, Open CCR/CCD Project

Agenda

• Pharmacy-driven Clinical Transformation

– Strategic Drug Selection: What, Why, How, When?

– Tip of the month

• Transformation Working Group Update

– Review of status

• Open Project Updates

– OpenVista/GT.M Integration

– CCD/CCR collaboration

Pharmacy-driven Clinical TransformationStrategic Drug Selection

Terry Meehan, Roy Gryskevich, Larry Washington, Medsphere

Joe Kiowski, Randy Adams, Midland Memorial

Poll

• What is your primary role within your organization today?

Poll

• What is the status of Computerized Physician Order Entry (CPOE) within your organization?

Strategic Drug Selection

• What is it?

• Why do it?

• Where to do it?

• How can it be done?

• When to do it?

• How is it measured?

• Who has done it?

Strategic Drug Selection: What is it?

• Within a drug class choose the optimum drug

– Effectively treats the target condition

– Safe

– Affordable

• Formulary Analysis

– Evidence-based literature reviews for effectiveness and safety

– Cost

– Recommendation to P&T committee

Strategic Drug Selection: What is it?

• Education– Inservice education– Publications – formulary listing– Website, Pharmacy Blog– Counter-detailing

• Formulary Decision Support Management – Allow / hide selection of orderable drug– Display costs– Set the formulary status

• Formulary Y/N in the drug file• Restrictions

– By indication– By specialty– By service

– Alternative options

Fileman Formulary List – (Tip of the Month Preview)

FORMULARY LIST BY VA CLASS & ORDERABLE APR 23,2009@09:56 PAGE 9

VA DRUG CLASS CODE

PHARMACY ORDERABLE ITEM GENERIC NAME

--------------------------------------------------------------------------------

AM112 PENICILLINASE-RESISTANT PENICILLI

DICLOXACILLIN DICLOXACILLIN NA 250MG CAP

NAFCILLIN NAFCILLIN NA 1GM/VI INJ

NAFCILLIN NAFCILLIN NA 1GM/VIL INJ ADD-VANTAG

NAFCILLIN NAFCILLIN NA 2GM/VI INJ

NAFCILLIN NAFCILLIN NA 2GM/VIL INJ ADD-VANTAG

AM113 EXTENDED SPECTRUM PENICILLINS

CLAVULANATE/TICARCILLIN TICARCILLIN 3GM/CLAV POT 0.1GM VL I

PIPERACIL 2/TAZOBAC 0.25/ISOTONIC 5 PIPERACIL 2/TAZOBAC 0.25GM/ISOTONIC

PIPERACIL 2/TAZOBAC 0.25GM VIAL PIPERACILLIN 2/TAZOBACTAM 0.25GM/VI

PIPERACIL 3/TAZOBAC 0.375GM VIAL PIPERACILLIN 3/TAZOBACTAM 0.375GM/V

Strategic Drug Selection: What is it?

• Formulary Decision Support Management

– Route options – IV/PO

• Route choices

• Dosage forms

– Liquid

– XR, CR (variable response, higher cost/dose, fewer doses per day)

• Conversion protocols

– Drug-specific messaging (instructions/ guidelines)

• What is it not?

– Patient specific

Poll

• Are you currently involved in the drug selection process within your organization?

Why do it?

• Freedom to choose?

• Freedom is just Chaos, with better lighting

– Alan Dean Foster, "To the Vanishing Point"

Why do it?

Why do it?

• High cholesterol?

– Pick a statin:

• atorvastatin

• lovastatin

• pravastatin

• fluvastatin

• rosuvastatin

• simvastatin

• cerivastatin

– Which is the most effective,safe and affordable?

Why do it?

• Control costs (inventory, storage, preparation, administration)

• Comply with Purchasing Group Preferred Drug contracts

• Drive best Practice

• Eliminate medications with safety risks or problem prone

• Include drugs within a class with favorable compliance and effectiveness properties

If it’s such a good idea, why allow overrides?

• Exceptions

– Institutional

• Purchasing agreement changes

• Shortages

• Payer limitations (CMS)

• Provider specialty (oncology, infectious disease)

– Patient-specific

• Patient response variance (pharmacogenomics)

• Drug interactions

• Allergies (inactive ingredients)

• Intolerance – side effect profiles

Strategic Drug Selection: Where to do it?

• Inpatient versus Outpatient

• Inpatient – driven by institutional oversight and cost – the EHR is a potentially effective tool

• Outpatient – driven by patient, prescriber, and payer

• FDS-mediated e-prescribing

– ($845,000/100,000 patients/18months)

How is it done?

• CPOE Medication order dialog

• Menu Screens

• Message and Warning configuration

• Proactively suggesting Formulary (Therapeutic) Alternatives

Formulary Mgmt. Pre-electronic record

• Document of approved Formulary items

– Alphabetic

– Therapeutic Class

• Physician writes orders in chart

• Pharmacist either accepts non-formulary med

• Pharmacist communicates with physician to change order

• Pharmacy and Therapeutic Committee approves auto-substitution of defined medications

Formulary Selection- Inpatient Medications

Default Route and Schedule

Non Formulary Indicator

Formulary Alternative in CIS

Pulmonary Specific Menu

Surgery Menu

Common Orders Menu

Restriction Display on CIS

Drug Text Message for Dosing

New Feature -- Special Instructions

When is it done?

• Phase II of Implementation Plan for New Customers

• On site visit several weeks after Go Live

• Part of Optimization of the software

How is it measured? - Reports

• Patients on Specific Drugs

– Monitor

• IV Cost reports

• Intervention Reports

• P&T Reports

• Inventory reports

• Fileman reports

– Pro

– Con

Who has done it?Midland Memorial Hospital, Midland Tx

• Joe Kiowski

– Pharmacy Data Systems Coordinator

• Randy Adams

– Pharmacy Coordinator

Midland Experience

Conclusion

• Questions

• Answers

• Discussion

Medsphere.org Tip of the Month

Stephanie Harper

FORMULARY DRUG FILEMAN REPORT

Print File Entries

Output from what File: DRUG// (5789 entries)SORT by: LOCAL NON-FORMULARY'=1;L1 By 'LOCAL NON', do you mean DRUG 'LOCAL NON-FORMULARY'? YesWithin LOCAL NON-FORMULARY'=1, SORT by: @VA CLASSIFICATION;SStart with VA CLASSIFICATION: FIRST//Within VA CLASSIFICATION, SORT by: PHARMACY ORDERABLE ITEMStart with PHARMACY ORDERABLE ITEM: FIRST//Within PHARMACY ORDERABLE ITEM, SORT by: GENERIC NAMEStart with GENERIC NAME: FIRST//Within GENERIC NAME, SORT by:

STORE IN 'SORT' TEMPLATE:

First Print FIELD: VA DRUG CLASS CODE;C1;N Then Print FIELD: PHARMACY ORDERABLE ITEM;L35;C3 Then Print FIELD: GENERIC NAME;L35Then Print FIELD:Heading (S/C): FORMULARY LIST BY DRUG CLASS & ORDERABLESTORE PRINT LOGIC IN TEMPLATE:START at PAGE: 1//DEVICE: TELNET

Example Report

FORMULARY LIST BY DRUG CLASS & ORDERABLE APR 23,2009@12:35 PAGE 1VA DRUG CLASS CODE

PHARMACY ORDERABLE ITEM GENERIC NAME---------------------------------------------------------------------------------------------------------------------------------AD100 ALCOHOL DETERRENTS

Acamprosate ACAMPROSATE CA 333MG EC TABDisulfiram DISULFIRAM (ANTABUSE) 250MG TAB

AD200 CYANIDE ANTIDOTESCyanide Antidote CYANIDE ANTIDOTE PACKAGE INJMethylene Blue METHYLENE BLUE 1% INJ 10MLMethylene Blue METHYLENE BLUE 1% INJ 1MLSodium Thiosulfate SODIUM THIOSULFATE 250MG/ML INJ 50M

AD300 HEAVY METAL ANTAGONISTSDeferoxamine DEFEROXAMINE MESYLATE 100MG/ML INJSuccimer SUCCIMER 100MG CAP

AD400 ANTIDOTES,DETERRENTS,AND POISON CSodium Polystyrene Sulfonate NA POLYSTYRENE SULF 50GM/200ML RTLSodium Polystyrene Sulfonate SOD POLYSTYRENE 15GM/60ML SUSP 60MLSodium Polystyrene Sulfonate SODIUM POLYSTY SULF 15GM/60ML SUSPSodium Polystyrene Sulfonate SODIUM POLYSTYRENE SULF 30GM/120MLSodium Polystyrene Sulfonate SODIUM POLYSTYRENE SULFONATE PWDR 4

AD900 ANTIDOTES/DETERRENTS,OTHERCharcoal CHARCOAL,ACTIVATED 25GM/120ML LIQ 1Charcoal,Activated 50g/240mL CHARCOAL,ACTIV 50GM/240ML LIQ 240MLCharcoal/Sorbitol CHARCOAL,ACT 50GM/SORBITOL 240ML LIChlorpheniramine/Epinephrine ANA-KITDigoxin Immune Fab DIGOXIN IMMUNE FAB (OVINE) 38MG/VILFlumazenil FLUMAZENIL 0.1MG/ML INJ 5MLInsect INSECT STING TREATMENT KIT INJMesna MESNA 100MG/ML INJ 10MLMesna MESNA 400MG TAB

How can I view the current formulary listing?

• FAQ: http://medsphere.org/docs/DOC-1452

Work Group Update: Clinical Transformation

Janine Powell

Open Development Projects

OpenVista/GT.M Integration Project

Jon Tai

Project Goals

� An all-open-source-software stack

� GT.M is an open source M engine

� Together with Linux and OpenVista, GT.M completes the stack

� Make it easier to install and manage OpenVista on GT.M and Linux

� Create native Linux packages of GT.M and management utilities

� Utilities should be optimized for OpenVista, GT.M, and Linux

− Do things “the Linux way” or “the GT.M way”

− Take advantage of as many existing open source components as possible

� Standardize best practices by coding them into the tools

� Make it easy to do the right thing and difficult to do the wrong thing

− Example: backups and journaling should be enabled by default

� Verify that all OpenVista components run properly on GT.M

Activity Stats

� Since the project started...

� 51 bugs filed

− Mainly “to do” items for developers

− Includes feature requests/enhancements

� 187 commits in 34 branches

� 8 blog posts

Current Status

� Almost code complete

� Linux utilities are complete and documented

� RPM packages built and ready for testing

� Working on merging M code into bzr and packaging the code in a KIDS build

� Getting ready for QA

� Developing more detailed test plans

− System-level and application-level tests

− Stress testing and benchmarking

This Month

� Finish documentation and packaging

� Publish RPMs and a “getting started” blog post

� Make it as easy as possible for the community to help us test

� Start internal testing

� Fix any issues that arise

Get Involved

� Be a beta tester!

� File bugs in Launchpad

� Help us brainstorm Phase II features

� Not sure how to get started?

� Post on Medsphere.org; we'll find something for you!

Opensource CCR and CCD supportfor VistA based systems

Project Update

March 26, 2009by

George Lillyglilly@glilly.net

* This project has been funded in part with Federal funds from the National Institutes of Health, under Contract No. H HSN268200425212C, “Re-engineering the Clinical Research Enterprise".

Reminders

Meetings and Project Info:

� CCD/CCR Project call:

� Meets: Every Tuesday @ 6pm Pacific

� http://groups.google.com/group/ccd-ccr-project

� Clinical Transformation Work Group

� Meets: 2nd Wed. of every month @ 10am Pacific

� http://medsphere.org/groups/clinical-transformation

� GT.M Integration

� http://medsphere.org/community/project/gtm

Community Projects and Discussion Lists:

� http://medsphere.org/docs/DOC-1376