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Webinar: http://www.medsphere.com/infinite/Voice: (888) 346-3950Participant code: 1302465
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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 [email protected]
* 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
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