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Pharmacy-driven Clinical Transformation

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April 2009 Community Call …

April 2009 Community Call

When integrated medication processes and automated cabinets are in place, pharmacists are enabled to practice more “clinical pharmacy”. Often this means getting pharmacists out of the basement and onto the floors where they are available to patients and their caregivers. One of pharmacy’s services is to promote a safe, effective, and economical list of preferred drugs. With well-designed EHR technology as a tool, pharmacists can proactively influence physicians to choose the “right” drug. They can also measure and report on compliance to formulary preferences. The goal of this session is to explore the options available and present experience with a program currently in place at one of our ecosystem sites.

This topic is both clinical and administrative in nature and will likely be useful to all pharmacy staff, clinical specialists involved in building/maintaining CPOE systems, physicians, nurses and others interested in pharmacy management, both from a clinical and fiscal perspective.

Please feel free to forward this invitation to any colleagues or associates who you believe would find this topic of interest or would like to participate in the discussion.

What: Pharmacy-driven Clinical Transformation
- Strategic Drug Selection
- What is it?
- Why do it?
- How can it be done?
- How is it measured?
- Who has done it?
- Transformation Working Group Update
- Review of status
- Open Project Updates
- OpenVista/GT.M Integration
- CCD/CCR collaboration
- Medsphere.org: Tip of the month

When: April 23, 12:30 - 2pm Pacific
Where: Dial-in: (888) 346-3950 // Participant Code: 1302465
Web conference: http://www.medsphere.com/infinite/

===
The community calls are listed on the Medsphere.org event calendar (http://medsphere.org/community-events/) and we will update each month's call as the agenda is solidified.

Details and Recording here: http://medsphere.org/blogs/events/2009/04/23/community-call-april-2009

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  • 1. Webinar: http://www.medsphere.com/infinite/ Voice: (888) 346-3950 Participant code: 1302465 Please mute your phone unless you have a question. Use your phone’s mute feature or use the conference system to do so (simply dial: *6 to mute/unmute)
  • 2. Pharmacy-driven Transformation April 2009 Community Call
  • 3. 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
  • 4. 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
  • 5. Pharmacy-driven Clinical Transformation Strategic Drug Selection Terry Meehan, Roy Gryskevich, Larry Washington, Medsphere Joe Kiowski, Randy Adams, Midland Memorial
  • 6. Poll • What is your primary role within your organization today?
  • 7. Poll • What is the status of Computerized Physician Order Entry (CPOE) within your organization?
  • 8. 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?
  • 9. 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
  • 10. 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
  • 11. 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
  • 12. 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
  • 13. Poll • Are you currently involved in the drug selection process within your organization?
  • 14. Why do it? • Freedom to choose? • Freedom is just Chaos, with better lighting – Alan Dean Foster, quot;To the Vanishing Pointquot;
  • 15. Why do it?
  • 16. Why do it? • High cholesterol? – Pick a statin: • atorvastatin • lovastatin • pravastatin • fluvastatin • rosuvastatin • simvastatin • cerivastatin – Which is the most effective,safe and affordable?
  • 17. 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
  • 18. 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
  • 19. 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)
  • 20. How is it done? • CPOE Medication order dialog • Menu Screens • Message and Warning configuration • Proactively suggesting Formulary (Therapeutic) Alternatives
  • 21. 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
  • 22. Formulary Selection- Inpatient Medications
  • 23. Default Route and Schedule
  • 24. Non Formulary Indicator
  • 25. Formulary Alternative in CIS
  • 26. Pulmonary Specific Menu
  • 27. Surgery Menu
  • 28. Common Orders Menu
  • 29. Restriction Display on CIS
  • 30. Drug Text Message for Dosing
  • 31. New Feature -- Special Instructions
  • 32. 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
  • 33. How is it measured? - Reports • Patients on Specific Drugs – Monitor • IV Cost reports • Intervention Reports • P&T Reports • Inventory reports • Fileman reports – Pro – Con
  • 34. Who has done it? Midland Memorial Hospital, Midland Tx • Joe Kiowski – Pharmacy Data Systems Coordinator • Randy Adams – Pharmacy Coordinator
  • 35. Midland Experience
  • 36. Conclusion • Questions • Answers • Discussion
  • 37. Medsphere.org Tip of the Month Stephanie Harper
  • 38. 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'? Yes Within LOCAL NON-FORMULARY'=1, SORT by: @VA CLASSIFICATION;S Start with VA CLASSIFICATION: FIRST// Within VA CLASSIFICATION, SORT by: PHARMACY ORDERABLE ITEM Start with PHARMACY ORDERABLE ITEM: FIRST// Within PHARMACY ORDERABLE ITEM, SORT by: GENERIC NAME Start 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;L35 Then Print FIELD: Heading (S/C): FORMULARY LIST BY DRUG CLASS & ORDERABLE STORE PRINT LOGIC IN TEMPLATE: START at PAGE: 1// DEVICE: TELNET
  • 39. Example Report FORMULARY LIST BY DRUG CLASS & ORDERABLE APR 23,2009@12:35 PAGE 1 VA DRUG CLASS CODE PHARMACY ORDERABLE ITEM GENERIC NAME --------------------------------------------------------------------------------------------------------------------------------- AD100 ALCOHOL DETERRENTS Acamprosate ACAMPROSATE CA 333MG EC TAB Disulfiram DISULFIRAM (ANTABUSE) 250MG TAB AD200 CYANIDE ANTIDOTES Cyanide Antidote CYANIDE ANTIDOTE PACKAGE INJ Methylene Blue METHYLENE BLUE 1% INJ 10ML Methylene Blue METHYLENE BLUE 1% INJ 1ML Sodium Thiosulfate SODIUM THIOSULFATE 250MG/ML INJ 50M AD300 HEAVY METAL ANTAGONISTS Deferoxamine DEFEROXAMINE MESYLATE 100MG/ML INJ Succimer SUCCIMER 100MG CAP AD400 ANTIDOTES,DETERRENTS,AND POISON C Sodium Polystyrene Sulfonate NA POLYSTYRENE SULF 50GM/200ML RTL Sodium Polystyrene Sulfonate SOD POLYSTYRENE 15GM/60ML SUSP 60ML Sodium Polystyrene Sulfonate SODIUM POLYSTY SULF 15GM/60ML SUSP Sodium Polystyrene Sulfonate SODIUM POLYSTYRENE SULF 30GM/120ML Sodium Polystyrene Sulfonate SODIUM POLYSTYRENE SULFONATE PWDR 4 AD900 ANTIDOTES/DETERRENTS,OTHER Charcoal CHARCOAL,ACTIVATED 25GM/120ML LIQ 1 Charcoal,Activated 50g/240mL CHARCOAL,ACTIV 50GM/240ML LIQ 240ML Charcoal/Sorbitol CHARCOAL,ACT 50GM/SORBITOL 240ML LI Chlorpheniramine/Epinephrine ANA-KIT Digoxin Immune Fab DIGOXIN IMMUNE FAB (OVINE) 38MG/VIL Flumazenil FLUMAZENIL 0.1MG/ML INJ 5ML Insect INSECT STING TREATMENT KIT INJ Mesna MESNA 100MG/ML INJ 10ML Mesna MESNA 400MG TAB
  • 40. How can I view the current formulary listing? • FAQ: http://medsphere.org/docs/DOC-1452
  • 41. Work Group Update: Clinical Transformation Janine Powell
  • 42. Open Development Projects
  • 43. OpenVista/GT.M Integration Project Jon Tai
  • 44. 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
  • 45. 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
  • 46. 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 −
  • 47. 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
  • 48. 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!
  • 49. Opensource CCR and CCD support for VistA based systems Project Update March 26, 2009 by George Lilly glilly@glilly.net * This project has been funded in part with Federal funds from the National Institutes of Health, under Contract No. HHSN268200425212C, “Re-engineering the Clinical Research Enterprisequot;.
  • 50. 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